Nokea
A nurse is assessing a preterm newborn. Which assessment findings are consistent with prematurity? (Select all that apply.)
- A. Abundant lanugo over the body
- B. Ear cartilage soft and pliable
- C. Flexed body posture
- D. Deep creases on the sole of the foot
Correct Answer: A
Rationale: Abundant lanugo over the body: Premature newborns often have abundant lanugo, which is fine, soft hair covering their bodies. This is a common characteristic of prematurity as the baby has not had enough time to shed this hair before birth.
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For a patient who is being discharged on digoxin, the nurse should include which of the ff. in an explanation to the patient on the signs and symptoms of digoxin toxicity?
- A. Poor appetite
- B. Halos around lights
- C. Constipation
- D. Tachycardia
Correct Answer: B
Rationale: Digoxin toxicity can manifest in various ways, but one common sign is the presence of visual disturbances such as seeing halos around lights. This is due to digoxin's effect on the optic nerve. Patients experiencing halos around lights should seek medical attention promptly as it may indicate a serious reaction to the medication. The other options (poor appetite, constipation, tachycardia) may occur with digoxin toxicity as well, but the visual disturbance of halos around lights is a classic and important sign to be aware of.
Tiffany is diagnosed with increased intracranial pressure (ICP); which of the following if stated by her parents would indicate a need for Nurse Charlie to reexplain the purpose for elevating the head of the bed at a 10 to 20-degree angle?
- A. Help alleviate headache
- B. Increase intrathoracic pressure
- C. Maintain neutral position
- D. Reduce intra-abdominal pressure.
Correct Answer: B
Rationale: Elevating the head of the bed at a 10 to 20-degree angle helps to increase intrathoracic pressure. This increase in pressure can aid in promoting cerebrospinal fluid drainage and reducing intracranial pressure. It is important to maintain the correct angle to achieve the desired effect and avoid potential complications. If Tiffany's parents mention this as the reason for elevating the bed, Nurse Charlie should reexplain the purpose to ensure they understand the intended outcome.
Nursing care for a patient who is experiencing a convulsive seizure includes all of the following except:
- A. Loosening constrictive clothing
- B. Opening the patient's jaw and inserting a mouth gag
- C. Positioning the patient on his or her side with head flexed forward
- D. Providing for privacy
Correct Answer: B
Rationale: Opening the patient's jaw and inserting a mouth gag is not part of the appropriate nursing care for a patient experiencing a convulsive seizure. Doing so can potentially harm the patient by causing injury to the teeth, jaw, or airway. It is important to protect the patient's airway during a seizure, but this can be done by positioning the patient on their side with the head flexed forward, ensuring a clear airway without the need for a mouth gag.
By the age of 7 months, the infant is able to do all the following EXCEPT
- A. transfer object from hand to hand
- B. actively bounces
- C. uses radial palm grasp
- D. roll over
Correct Answer: D
Rationale: Rolling over is usually achieved earlier, by 4-6 months, while other skills are typical for 7 months.
Which of the following malignancies is least likely to occur in a 10-month-old infant?
- A. neuroblastoma
- B. nephroblastoma
- C. retinoblastoma
- D. hepatoblastoma
Correct Answer: D
Rationale: Hepatoblastoma is rare in infants under 1 year old, being more common in toddlers.