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A nurse is assessing a newborn following a circumcision. Which of the following should the nurse identify as an indication that the newborn is experiencing pain?
- A. Decreased heart rate
- B. Chin quivering
- C. Pinpoint pupils
- D. Slowed respirations
Correct Answer: B
Rationale: The correct answer is B: Chin quivering. This is a common sign of pain in newborns as they may not be able to communicate verbally. It indicates distress and discomfort. Decreased heart rate (A) and pinpoint pupils (C) are not indicative of pain but rather can be signs of other medical conditions. Slowed respirations (D) can be a sign of distress but not specifically pain. Therefore, B is the most relevant and specific indicator of pain in this scenario.
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The client who is scheduled for a nonstress test (NST) asks the nurse to explain the purpose of the test. Which of the following is the correct response?
- A. The purpose of the NST is to assess the fetal CNS.
- B. The purpose of the NST helps to determine gestational age.
- C. The purpose of the NST is to determine fetal lie.
- D. The purpose of the NST is to determine fetal breathing.
Correct Answer: A
Rationale: The correct answer is A: The purpose of the NST is to assess the fetal CNS. The nonstress test (NST) evaluates the fetal CNS by measuring the fetal heart rate in response to fetal movement. This test assesses the overall well-being of the fetus by monitoring for accelerations in the heart rate, indicating a healthy CNS. Choices B, C, and D are incorrect because the NST is not used to determine gestational age, fetal lie, or fetal breathing. The primary focus of the NST is to evaluate the fetal CNS function through monitoring the fetal heart rate patterns.
A 35-week gestation infant was delivered by forceps. Which assessment findings should alert the nurse to a possible complication of the forceps delivery?
- A. Weak, ineffective suck, and scalp edema
- B. Molding of the head and jitteriness
- C. Shrill, high pitched cry, and tachypnea
- D. Hypothermia and hemoglobin of 12.5 g/dL
Correct Answer: A
Rationale: The correct answer is A: Weak, ineffective suck, and scalp edema. Forceps delivery can cause head trauma leading to facial nerve injury, resulting in weak suck and scalp edema. Molding of the head (choice B) is a normal finding after vaginal birth. Jitteriness (choice B) may be due to immaturity rather than a complication of forceps delivery. A shrill, high-pitched cry and tachypnea (choice C) are more indicative of respiratory distress, not specific to forceps delivery. Hypothermia and hemoglobin of 12.5 g/dL (choice D) are not directly related to complications of forceps delivery.
A client at ten weeks gestation tells the nurse that she has been having 'morning sickness.' The nurse advises the client to eat foods that are easy to digest and low in fat. Which is the rationale for the nurse's instruction?
- A. A low-fat diet increases peristalsis,which reduces the food volume in the stomach
- B. A low-fat diet is digested faster and leaves less in the stomach that can be vomited
- C. Easily digested foods provide a better balance of fluids and electrolytes, resulting in less nausea and vomiting
- D. Easily digested foods are less likely to cause relaxation of the cardiac sphincter, which causes regurgitation and vomiting
Correct Answer: B
Rationale: The correct answer is B: A low-fat diet is digested faster and leaves less in the stomach that can be vomited. During pregnancy, hormonal changes can lead to morning sickness. Eating foods that are low in fat helps reduce the workload on the digestive system, allowing for quicker digestion. This means there is less food remaining in the stomach that could potentially trigger vomiting. Therefore, advising the client to eat low-fat foods can help alleviate morning sickness symptoms.
A: Incorrect. While a low-fat diet may aid in digestion, it does not specifically increase peristalsis to reduce food volume in the stomach.
C: Incorrect. While easily digested foods can be beneficial, the primary focus in this scenario is on reducing fat intake for faster digestion.
D: Incorrect. The issue of cardiac sphincter relaxation and vomiting is not directly related to the advice given by the nurse.
A nurse is caring for a 3-year-old child with strabismus. Which of the following actions should the nurse advise the parents to implement to help prevent amblyopia?
- A. Wear corrective biconcave lenses.
- B. Prevent trauma to the eyes.
- C. Patch the strong eye.
- D. Instill artificial tears.
Correct Answer: C
Rationale: The correct answer is C: Patch the strong eye. Patching the strong eye helps improve vision in the weaker eye, which is essential in preventing amblyopia. By covering the strong eye, the brain is forced to rely on the weaker eye, strengthening its visual acuity. Wearing corrective biconcave lenses may help with refractive errors but does not directly address amblyopia prevention. Preventing trauma to the eyes is important for overall eye health but does not specifically target amblyopia prevention. Instilling artificial tears is used for dry eye syndrome and does not play a role in preventing amblyopia.
A woman in the transition stage of labor is using paced breathing to relieve pain. She complains of blurred vision, numbness, and tingling of her hands and mouth. Which condition is indicated by these signs and symptoms?
- A. Anoxia
- B. Hyperventilation
- C. Anxiety
- D. Hypertension
Correct Answer: B
Rationale: The correct answer is B: Hyperventilation. The symptoms of blurred vision, numbness, and tingling in the hands and mouth are indicative of hyperventilation. During paced breathing, if the woman breathes too quickly or deeply, it can lead to a decrease in carbon dioxide levels in the blood, causing these symptoms. To address this, the woman should be guided to slow down her breathing and breathe into a paper bag to rebreathe some carbon dioxide. Anoxia (A) is a severe lack of oxygen, which would present with different symptoms. Anxiety (C) may cause similar symptoms but is not the primary issue here. Hypertension (D) does not typically lead to these specific symptoms.