Nokea
A newborn's birth was prolonged because the shoulders were very wide. The nurse performing the assessment would be particularly observant for a problem with the:
- A. Moro reflex
- B. Plantar reflex
- C. Babinski reflex
- D. Stepping reflex
Correct Answer: B
Rationale: Shoulder dystocia can affect the plantar reflex.
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What behavior indicates effective teaching about the temperature rhythm method of fertility control?
- A. The woman takes her basal body temperature before retiring each evening.
- B. The couple charts information from at least six menstrual cycles before using the method.
- C. The couple resumes having intercourse as soon as they see a rise in the basal body temperature.
- D. The woman assesses her vaginal discharge daily for changes in color and odor.
Correct Answer: B
Rationale: Charting multiple cycles helps identify the fertile window accurately.
A patient has expressed interest in receiving an implant for contraception. Which statements by the patient show that she understands the teaching given to her about her procedure and medication? Select one that does not apply.
- A. I do not have to worry about getting pregnant for 3 years.
- B. I will need someone to come to the office with me to drive me home the day of the procedure.
- C. This medication could cause irregular bleeding.
- D. I do not have to worry about STIs when I have this device placed.
Correct Answer: D
Rationale: The implant provides long-term contraception for 3 years, so the patient should understand it is a long-term method. Choice A is correct, and the patient must be aware of this. Choice B is correct, as the procedure involves a minor surgical process, and the patient will need someone to drive them home. Choice C is correct because irregular bleeding is a common side effect of the implant. Choice D is incorrect, as the implant does not provide STI protection.
The nurse is caring for a woman with a broken arm. Her partner brings in flowers and balloons and is overly affectionate. What phase of the cycle of violence would the nurse suspect?
- A. tension-building
- B. acute battering incident
- C. honeymoon phase
- D. loving phase
Correct Answer: C
Rationale: The honeymoon phase in the cycle of violence is characterized by remorse and attempts by the abuser to regain control through affection or gifts. This phase manipulates the victim into believing the abuse will not recur.
The nurse is administering a number of therapeutic interventions for neonates, infants, and children on the pediatric unit. Which intervention contributes to an increase in chronic illness seen in early childhood?
- A. Administering antibiotics to prevent lethal infections
- B. Vaccinating children to prevent childhood diseases
- C. Using mechanical ventilation for premature infants
- D. Using corticosteroids as a treatment for asthma
Correct Answer: C
Rationale: Using mechanical ventilation and medications to foster lung development in premature infants increases their survival rate. Yet the infants who survive are often faced with myriad chronic illnesses.
A 2-week-old neonate is admitted to the hospital with a diagnosis of possible sepsis. The neonate weighs 3.2 kg, The health care provider prescribes the following orders for the neonate and signs the order sheet. Which order would the nurse question? Progress Notes: 12/01/22- 10am
- A. Acetaminophen (Tylenol) 10mg/kg per rectum every 4-6 hours prn for pain
- B. Ampicillin 200mg/kg IV every 6 hours in D5.45 NSSIV @ 125ml/hr.
- C. Mom may breastfeed ad lib
- D. Draw blood cultures x 3 in A.M.
Correct Answer: B
Rationale: Ampicillin dosage exceeds recommended levels for neonates.