Nokea
A newborn has a respiratory rate of 80 breaths/min, nasal flaring with sternal retractions, a heart rate of 120 beats/min, temperature of 36C and a persisting oxygen saturation of <87%. The nurse interprets these findings as:
- A. Cardiac distress
- B. Respiratory Alkalosis
- C. Bronchial pneumonia
- D. Respiratory Distress
Correct Answer: D
Rationale: These signs indicate respiratory distress.
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What statement by a client suggests the relationship may be in the 'honeymoon phase'?
- A. My partner said that he will never hurt me again.
- B. My partner drinks alcohol only on the weekends.
- C. My partner yells less than he used to.
- D. My partner has frequent bouts of insomnia.
Correct Answer: A
Rationale: Promises to stop abuse characterize the honeymoon phase.
What should be included in teaching a client undergoing a bilateral tubal ligation?
- A. The surgical procedure is easily reversible.
- B. Menstruation usually ceases after the procedure.
- C. Libido should remain the same after the procedure.
- D. The incision will be made endocervically.
Correct Answer: C
Rationale: Tubal ligation does not affect libido.
The nurse would classify a newborn delivered at 39 weeks' gestation, weighing 2400 g ( 5.0 lbs) as being:
- A. Preterm and immature
- B. Small-for-gestational age
- C. Average-for-gestational age
- D. Average-for-gestational age but pre-term
Correct Answer: B
Rationale: Weight below the 10th percentile indicates small-for-gestational age.
Screening at 24 weeks gestation reveals that a pregnant woman has gestational diabetes mellitus (GDM). In planning the woman9s care. The nurse and the woman mutually agree that an expected outcome is to prevent injury to the fetus due to the GDM. The nurse identifies that the fetus is at risk for which of the following? Congenital anomalies of the central nervous system Macrosomia Preterm birth Low birth weight Screening at 24 weeks of gestation reveals that a pregnant woman has gestational diabetes mellitus (GDM). In planning her care, the nurse and the woman mutually agree that an expected outcome is to prevent injury to the fetus as a result of GDM. The nurse identifies that the fetus is at greatest risk for:
- A. macrosomia.
- B. congenital anomalies of the central nervous system.
- C. preterm birth.
- D. low birth weight. A
Correct Answer: A
Rationale: Gestational diabetes mellitus (GDM) is a condition where high blood sugar levels develop during pregnancy in women who didn't have diabetes before pregnancy. One of the primary risks associated with GDM is fetal overgrowth, also known as macrosomia. This means the baby is larger than normal. Macrosomia can lead to complications during delivery, such as shoulder dystocia (when the baby's shoulders get stuck during delivery) and an increased risk of birth injuries for both the baby and the mother. It can also increase the likelihood of a cesarean section delivery. Therefore, preventing macrosomia is an important goal in managing GDM to ensure the safety and well-being of both the mother and the baby.
What information should be included in teaching an uncircumcised male to use a condom?
- A. Apply mineral oil to the shaft of the penis after applying the condom.
- B. Pull back the foreskin before applying the condom.
- C. Create a reservoir at the tip of the condom after putting it on.
- D. Wait five minutes after ejaculating before removing the condom.
Correct Answer: B
Rationale: Pulling back the foreskin ensures proper placement of the condom.