Nokea
A nurse has completed an assessment on a newborn. Which finding is considered abnormal?
- A. Nystagmus
- B. Profuse drooling
- C. Dark green or black stools
- D. Slight vaginal reddish discharge
Correct Answer: A
Rationale: Nystagmus refers to involuntary and repetitive eye movements. It is considered abnormal in a newborn as it may be a sign of a neurological or visual problem. Therefore, if a nurse observes nystagmus during a newborn assessment, it should be further investigated and discussed with a healthcare provider to determine the underlying cause and appropriate management. Profuse drooling, dark green or black stools, and slight vaginal reddish discharge are common findings in newborns and do not typically indicate a serious health issue.
You may also like to solve these questions
The nurse is caring for a newborn who was born 24 hours ago to a mother who received no prenatal care. The newborn is a poor feeder but sucks avidly on his hands. Clinical manifestations also include loose stools, tachycardia, fever, projectile vomiting, sneezing, and generalized sweating. Which should the nurse suspect?
- A. Seizure disorder
- B. Narcotic withdrawal
- C. Placental insufficiency
- D. Meconium aspiration syndrome
Correct Answer: B
Rationale: The clinical manifestations described in the scenario are classic signs of neonatal abstinence syndrome (NAS), which occurs in newborns who were exposed to drugs, particularly narcotics, in utero. The newborn's symptoms of poor feeding, sucking on his hands, tachycardia, fever, projectile vomiting, loose stools, sneezing, and generalized sweating are consistent with NAS. These symptoms occur as the newborn experiences withdrawal from the drugs to which they were exposed during pregnancy. In this case, the lack of prenatal care suggests that the mother may have used narcotics during pregnancy, leading to NAS in the newborn. It is essential for healthcare providers to recognize these signs and provide appropriate care and support for infants experiencing NAS.
Nearly all cervical carcinomas contain human papillomavirus (HPV). Which of the following types is never associated with such malignancy?
- A. type6
- B. type 16
- C. type 18
- D. type 31
Correct Answer: A
Rationale: HPV type 6 is typically associated with low-grade lesions and genital warts, not cervical carcinoma.
A 52-year old female tells the nurse that she has found a painless lump in her right breast during her monthly self-examination. Which assessment finding would strongly suggest that this client's lump is cancerous?
- A. Eversion of the right nipple and mobile
- B. Mobile mass that is soft and easily mass delineated
- C. Non-mobile mass with irregular edges
- D. Non palpable right axillary lymph nodes
Correct Answer: C
Rationale: A non-mobile mass with irregular edges is a strong indicator of a cancerous lump in the breast. Cancerous lumps often feel fixed or attached to the surrounding tissue and may have irregular shapes rather than smooth, round contours. The lack of mobility and irregular edges increase suspicion for malignancy and warrant further investigation, such as imaging studies and biopsies. It is important for this patient to follow up with a healthcare provider promptly for further evaluation and appropriate management.
An infant with gastroschisis is MORE likely than one with an omphalocele to have which of the following conditions?
- A. Congenital heart disease
- B. History of prematurity
- C. Imperforate anus
- D. N/A
Correct Answer: B
Rationale: Infants with gastroschisis are more likely to have a history of prematurity compared to those with omphalocele, though neither condition is strongly associated with congenital heart disease or imperforate anus.
Building a tower by a 22-month-old child requires
- A. visual-motor coordination
- B. uses visual and motor skills in combination
- C. gross and fine motor coordination
- D. symbolic thought
Correct Answer: A
Rationale: Tower building primarily involves visual-motor coordination.