Nokea
A nurse auscultates a loud cardiac murmur on a newborn with suspected trisomy 21 (Down syndrome). A genetic screen and an echocardiogram are scheduled that day. The neonate’s vital signs are shown in the exhibit. What would be an appropriate action for the nurse to complete next?
- A. Call the health care provider immediately
- B. Document the finding
- C. Place the neonate in a knee-chest position
- D. Provide oxygen to the neonate
Correct Answer: B
Rationale: Documenting the murmur is appropriate as genetic screening and an echocardiogram are already scheduled, indicating the provider is aware. Calling the provider is unnecessary, knee-chest position is for specific heart defects, and oxygen is not indicated without respiratory distress.
You may also like to solve these questions
Rehabilitation services begin:
- A. when the client enters the health care system.
- B. after the client requests rehabilitation services.
- C. after the client's physical condition stabilizes.
- D. when the client is discharged from the hospital.
Correct Answer: A
Rationale: Rehabilitation starts upon entry into the healthcare system to maximize recovery from the outset. Waiting for stabilization or discharge delays optimal intervention. Health Promotion and Maintenance
Which discharge teaching instructions should the nurse reinforce to the parents of a 2-year-old with group A streptococcal pharyngitis? Select all that apply.
- A. Complete all the antibiotics even if your child is feeling better
- B. Cool liquids and soft diet are recommended
- C. Keep your child home from daycare for at least a week
- D. Replace your child’s toothbrush 24 hours after starting antibiotics
- E. Throat lozenges may soothe your child’s sore throat
Correct Answer: A,B,D
Rationale: Completing antibiotics prevents resistance, cool liquids/soft foods ease swallowing, and replacing the toothbrush prevents reinfection. A week-long daycare exclusion is excessive (24-48 hours post-antibiotics is sufficient), and lozenges are unsafe for a 2-year-old due to choking risk.
Fat emulsions are frequently administered as a part of total parenteral nutrition. Which statement is true regarding fat emulsions?
- A. They have a high energy-to-fluid-volume ratio.
- B. Even though hypertonic, they are well tolerated.
- C. They are a basic solution secondary to the addition of sodium hydroxide (NaOH).
- D. The pH is alkaline, making them compatible with most medications.
Correct Answer: A
Rationale: Fat emulsions provide a high energy-to-fluid-volume ratio (e.g., 2 kcal/mL for 20% solutions), making them efficient for TPN. They are isotonic and pH-neutral, not hypertonic or alkaline. Pharmacological Therapies
The nurse is teaching a teenage female about preventing the transmission of genital herpes. Which of the following statements should the nurse include?
- A. Do not sit on toilet seats without protection.'
- B. Oral sex does not transmit the virus.'
- C. This infection can be transmitted via intercourse even when you do not feel ill.'
- D. Try to drink lots of fluids after sex to flush the reproductive tract.'
Correct Answer: C
Rationale: Genital herpes can be transmitted during asymptomatic periods via sexual contact, including intercourse. The other statements are myths or irrelevant to prevention. Safety and Infection Control
A client’s partner asks the nurse if ‘staring off into space’ is a seizure because the client ‘does that sometimes when having a seizure.’ Which response from the nurse is the most helpful?
- A. No, absence seizures can look like daydreaming or staring off into space.
- B. No, you are wrong. Don’t worry about that.
- C. Yes, so please let me know if you see the client do that.
- D. You don’t have to monitor the client for seizures.
Correct Answer: A
Rationale: Explaining that absence seizures can appear as staring or daydreaming educates the partner accurately and encourages reporting without alarm. Dismissing the concern, assuming it’s a seizure, or discouraging monitoring is unhelpful and potentially unsafe.