Nokea
A nurse is assessing a newborn 12 hours after birth. Which of the following findings should be reported to the physician immediately?
- A. Milia on the nose
- B. Mongolian spots on the back
- C. Caput succedaneum
- D. Jaundice on the face
Correct Answer: D
Rationale: Jaundice within 24 hours of birth is pathological and requires immediate evaluation. Milia, Mongolian spots, and caput succedaneum are normal findings.
You may also like to solve these questions
When you are monitoring your client who is now started on an intravenous antibiotic for an infection, you notice that the client is exhibiting signs of anaphylaxis. What is your first priority intervention?
- A. Stop the intravenous flow
- B. Slow down the intravenous flow
- C. Notify the doctor
- D. Begin CPR
Correct Answer: A
Rationale: Stopping the IV flow is the first priority to halt the administration of the allergen causing anaphylaxis, followed by other emergency interventions.
Which client should the nurse delegate to the unlicensed assistive personnel (UAP)?
- A. A client who needs teaching regarding the use of an incentive spirometer
- B. A client who needs to have a urine specimen collected for a clean catch urine
- C. A client who needs reinforcement of a dressing covering an abdominal incision
- D. A client who needs assessment of a newly identified area of pressure over the right hip
Correct Answer: B
Rationale: The UAP can assist with specimen collection such as a clean catch urine because he or she is trained in this skill. Skills requiring nursing intervention such as dressing changes, teaching, and assessment cannot be delegated to unlicensed personnel.
The nurse caring for a child diagnosed with a patent ductus arteriosus should base planning on which fact concerning this disorder?
- A. It involves an opening between the two atria.
- B. It produces abnormalities in the atrial septum.
- C. It involves an opening between the two ventricles.
- D. It involves an artery that connects the aorta and the pulmonary artery.
Correct Answer: D
Rationale: Patent ductus arteriosus is described as an artery that connects the aorta and the pulmonary artery during fetal life. It generally closes spontaneously within a few hours to several days after birth. It allows abnormal blood flow from the high-pressure aorta to the low-pressure pulmonary artery, resulting in a left-to-right shunt. The remaining options are not characteristics of this cardiac defect.
The nurse is assessing a client with a suspected bowel obstruction. Which of the following findings is most indicative of this condition?
- A. Abdominal distension.
- B. Decreased bowel sounds.
- C. Soft, nontender abdomen.
- D. Frequent loose stools.
Correct Answer: A,B
Rationale: Abdominal distension and decreased bowel sounds are hallmark signs of bowel obstruction due to blocked intestinal passage.
Which of the following should be the nurse's priority assessment after an epidural anesthetic has been administered to a client in labor?
- A. Level of consciousness.
- B. Blood pressure.
- C. Cognitive function.
- D. Contraction pattern.
Correct Answer: B
Rationale: Epidurals can cause hypotension due to vasodilation, making blood pressure the priority assessment.