Nokea
A nurse is assessing a newborn upon admission to the nursery. Which of the following should the nurse expect?
- A. Bulging Fontanels
- B. Nasal Flaring
- C. Length from head to heel of 40 cm (15.7 in)
- D. Chest circumference 2 cm (0.8 in) smaller than the head circumference
Correct Answer: D
Rationale: When a nurse is assessing a newborn upon admission to the nursery, it is expected that the chest circumference will be smaller than the head circumference. This is a normal finding in a newborn, where the head circumference is slightly larger than the chest circumference due to the proportionate sizes of the newborn's head and chest. This difference helps accommodate the vital organs within the chest cavity while allowing for the growth and development of the brain. Therefore, a chest circumference that is 2 cm smaller than the head circumference is a typical and expected finding in a newborn assessment.
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The nurse is teaching a client about kick counts. When should the client contact the healthcare provider?
- A. Fewer than 10 movements in 2 hours.
- B. Fewer than 20 movements in 1 hour.
- C. No movement in 4 hours.
- D. No movement after eating a meal.
Correct Answer: A
Rationale: Fewer than 10 fetal movements in 2 hours is concerning and warrants further evaluation.
A patient has just had a Mirena IUD inserted. What is the most important information for the nurse to include in the post-procedure instructions?
- A. You may experience severe cramping and should rest for several days.
- B. You should check the strings of the IUD regularly to ensure it is in place.
- C. You should avoid sexual activity for the first month after the insertion.
- D. The IUD will make your periods longer and heavier for the first 6 months.
Correct Answer: B
Rationale: The patient should be instructed to check the strings of the IUD regularly to ensure it remains in place. Choice A is not accurate because while cramping is common, rest is not necessarily required for several days. Choice C is not required; there is no need to avoid sexual activity unless there is an infection or other complication. Choice D is incorrect as Mirena typically reduces bleeding or makes periods lighter.
What does the nursing process describe?
- A. what nurses do
- B. how nurses think
- C. where nurses provide care
- D. who nurses care for
Correct Answer: B
Rationale: The nursing process describes how nurses think and approach patient care. It is a systematic problem-solving approach that nurses use to provide individualized patient care. The nursing process consists of five main steps: assessment, diagnosis, planning, implementation, and evaluation. Through this process, nurses gather information, identify patient problems, set goals, implement interventions, and evaluate outcomes. By following the nursing process, nurses can deliver holistic and effective care to their patients.
A woman admitted to the labor and delivery unit in bruising over the shoulder area and an abrasion on early labor gives the following obstetric history. She the scalp. What are these markings most likely the gave birth to her daughter at 38 weeks and her twin result of?
- A. Suspected drug use during pregnancy
- B. Abuse by a caregiver
- C. Soft tissue injury during delivery
- D. Blue/gray macule (Mongolian spot)
Correct Answer: B
Rationale: The bruising over the shoulder area and the abrasion on the scalp of a woman admitted to the labor and delivery unit during early labor are most likely the result of abuse by a caregiver. These types of injuries can be indicative of physical abuse, especially in vulnerable populations such as pregnant women. It is important for healthcare providers to be alert for signs of abuse and to report any suspicions or evidence to ensure the safety of the mother and the baby. In cases like this, a thorough assessment and appropriate intervention are necessary to protect the well-being of the mother and the unborn child.
What are the modes of heat loss in babies? SATA
- A. Radiation
- B. Conduction
- C. Convection
- D. Perspiration (baby's don't perspir
Correct Answer: A
Rationale: A. Radiation: Heat loss through radiation occurs when the baby is near a cold surface or in a drafty room, causing heat to transfer from the baby's body to the surrounding environment.