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A nurse is doing an assessment on a newborn. Which is characteristic of a newborn's vision at birth and an expected finding during the assessment?
- A. Ciliary muscles are mature.
- B. Blink reflex is absent.
- C. Tear glands function.
- D. Pupils react to light.
Correct Answer: D
Rationale: At birth, a newborn's vision is not fully developed. However, one of the characteristics of a newborn's vision is that their pupils are able to react to light. This response helps to protect the newborn's developing eyes from excessive light exposure. During a newborn assessment, it is expected that the nurse will observe the pupil constriction in response to a bright light source, indicating a normal functioning of the pupillary reflex. This physiological response is vital for assessing the newborn's neurological integrity and visual function.
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To reduce symptoms of early morning stiffness in a ptient who has rheumatoid arthritis, the nurse can encourage the patient to:
- A. take a hot tub bath or shower in the morning
- B. put joints through passive ROM before tryoing to move them actively
- C. sleep with a hot pad
- D. take two aspirins before arising, and wait 15 minutes before attempting locomotion
Correct Answer: A
Rationale: Taking a hot tub bath or shower in the morning can help reduce symptoms of early morning stiffness in a patient with rheumatoid arthritis. The warmth from the water helps relax muscles and joints, making it easier for the patient to move and start their day. Heat therapy is a common recommendation for managing joint stiffness in arthritis patients. This simple and effective method can improve flexibility and decrease pain associated with morning stiffness.
A nurse is planning a class on accident prevention for parents of toddlers. Which safety topic is the priority for this class?
- A. Appropriate use of car seat restraints
- B. Safety crossing the street
- C. Helmet use when riding a bicycle
- D. Poison control numbers
Correct Answer: A
Rationale: The safety topic that is the priority for the nurse's accident prevention class for parents of toddlers is the appropriate use of car seat restraints. Car accidents are one of the leading causes of injuries and deaths among children, and proper car seat usage is crucial in protecting toddlers during car rides. Following the guidelines for car seat installation and usage can significantly reduce the risk of injury or death in the event of a car accident. Therefore, ensuring that parents understand and implement proper car seat restraint practices is essential in promoting the safety of toddlers. While the other safety topics are also important, the risk of injury or death in car accidents is higher compared to other accidents for toddlers, making car seat safety a priority.
In terms of gross motor development, which should the nurse expect a 5-month-old infant to do? (Select all that apply.)
- A. Roll from abdomen to back.
- B. Put feet in mouth when supine.
- C. Roll from back to abdomen.
- D. Sit erect without support.
Correct Answer: A
Rationale: At 5 months old, an infant would typically be able to roll from abdomen to back (Choice A). This is an important gross motor skill that develops during this stage. Additionally, putting their feet in their mouth when lying on their back (Choice B) is also a common movement seen at this age. Both these actions demonstrate the increasing strength and coordination of the infant's muscles as they develop and explore their physical abilities. Rolling from back to abdomen (Choice C) and sitting erect without support (Choice D) typically develop later, around 6-7 months and 8-9 months, respectively. Moving from prone to sitting position (Choice E) and adjusting posture to reach an object (Choice F) are usually mastered around 8-9 months as well.
Which of the ff factors predisposes a client to the development of TB?
- A. Exposure to toxic gases
- B. Congenital abnormalities
- C. Obstruction by tumor
- D. Malnutrition
Correct Answer: D
Rationale: Malnutrition predisposes a client to the development of Tuberculosis (TB) because a lack of proper nutrition weakens the immune system, making the individual more susceptible to infections such as TB. Adequate nutrition is essential for maintaining a healthy immune system that can effectively fight off pathogens. Malnourished individuals are less able to mount a strong immune response, thus increasing their vulnerability to contracting TB and experiencing more severe symptoms and complications from the disease.
A mother tells the nurse that she is discontinuing breastfeeding her 5-month-old infant. What should the nurse recommend the infant be given?
- A. Skim milk
- B. Whole cow's milk
- C. Commercial iron-fortified formula
- D. Commercial formula without iron
Correct Answer: C
Rationale: When a mother decides to discontinue breastfeeding, it is important for the infant to receive an appropriate alternative that provides essential nutrients, including iron. Commercial iron-fortified formula ensures that the infant is receiving adequate iron, which is crucial for healthy growth and development. Skim milk is not recommended for infants under age 1 due to its high protein and mineral content, which can strain the baby's immature kidneys. Whole cow's milk is also not suitable before age 1 because it lacks essential nutrients such as iron and vitamin E, and can lead to iron deficiency anemia. Commercial formula without iron would not provide enough iron for the infant's needs, making commercial iron-fortified formula the most appropriate choice for the 5-month-old infant.