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A nurse is performing a gestational age assessment on a newborn. The nurse determines that the newborn is "term" if which findings are assessed? (Select all that apply.)
- A. Posture with fully flexed arms and legs
- B. Arm recoil brisk
- C. Square window at 90 degrees
- D. Scarf sign of elbow crossing over the midline
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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Which is most descriptive of the clinical manifestations observed in neonatal sepsis?
- A. Seizures and sunken fontanels
- B. Sudden hyperthermia and profuse sweating
- C. Decreased urinary output and frequent stools
- D. Nonspecific physical signs with hypothermia
Correct Answer: D
Rationale: Neonatal sepsis is a serious condition in newborns that is challenging to diagnose due to nonspecific and variable clinical signs. Some of the common manifestations of neonatal sepsis include poor feeding, lethargy, unstable temperature (hypothermia or hyperthermia), respiratory distress, apnea, irritability, and jaundice. The presence of hypothermia is often noted in neonatal sepsis, but it is essential to keep in mind that clinical signs can be subtle and nonspecific in these cases. Seizures, sudden hyperthermia, profuse sweating, decreased urinary output, and frequent stools are less specific to neonatal sepsis and may be seen in other conditions as well. Regular monitoring, prompt evaluation, and appropriate treatment are crucial in managing neonatal sepsis due to the nonspecific nature of its clinical presentation.
A client is admitted for postoperative assessment and recovery after surgery for a kidney tumor. The nurse needs to assess for signs of urinary tract infection. Which of the ff measures can be used to help detect UTI?
- A. Encourage the client to breathe deeply and cough every 2hrs
- B. Monitor temperature every 4hrs
- C. Splint the incision when repositioning the client
- D. Irrigate tubes as ordered CARING FOR CLIENTS WITH DISORDERS OF THE BLADDER AND URETHRA
Correct Answer: B
Rationale: Monitoring temperature every 4 hours is crucial in detecting signs of a urinary tract infection in a postoperative client. An increase in temperature can indicate the presence of an infection, and early identification is essential for prompt treatment. While coughing and deep breathing (Option A) are beneficial for postoperative clients to prevent respiratory complications, they are not directly related to detecting UTI. Splinting the incision (Option C) is important for incisional care but does not specifically help in detecting UTI. Irrigating tubes (Option D) should only be done as ordered by the healthcare provider and is not a routine measure for detecting UTI.
A patient has been prescribed bumetanide (Bumex) every morning for control of hypertension. Which of the ff. statements indicates correct knowledge of the treatment regimen?
- A. "I can travel to Florida and sunbathe all day."
- B. "Now I can eat whatever I want, whenever I want."
- C. "I'll take my medication in the morning, every morning."
- D. "I won't need medication once my pressure goes down."
Correct Answer: C
Rationale: The correct statement indicating the patient has a good understanding of the treatment regimen is statement C: "I'll take my medication in the morning, every morning." This statement shows that the patient acknowledges the importance of taking their prescribed bumetanide (Bumex) every morning as directed. Consistency in taking the medication as prescribed is crucial for the effective control of hypertension. Statements A and B are unrelated to the treatment regimen and do not address medication adherence. Statement D reflects a misconception that medication can be stopped once blood pressure decreases, which is inaccurate and potentially harmful.
Which of the following intravenous solutions is hypotonic?
- A. Normal saline
- B. Ringer's lactate
- C. 0.45% saline
- D. 5% dextrose in normal saline  A1 PASSERS TRAINING, RESEARCH, REVIEW & DEVELOPMENT COMPANY MEDICAL SURGICAL NURSING SET F
Correct Answer: C
Rationale: A hypotonic solution has a lower concentration of solutes compared to the cells in the body. 0.45% saline is hypotonic because it has a lower concentration of sodium chloride compared to the normal extracellular fluid in the body. When this solution is administered intravenously, water will move into the cells to balance the concentration gradient, potentially causing cellular swelling. A hypotonic solution is used to rehydrate cells in cases of hypernatremia or dehydration with cellular dehydration.
Which of the following would the nurse identify as an abnormal finding?
- A. Red blood cells (RBCs): 4.9million/ul
- B. Hematocrit: 45%
- C. Platelets: 115,000/ul
- D. None of the above
Correct Answer: C
Rationale: The normal range for platelets in adults is typically between 150,000 to 400,000 platelets per microliter of blood. A platelet count of 115,000/ul would be considered low, a condition known as thrombocytopenia. Thrombocytopenia can result in difficulty with blood clotting and may lead to increased risk of bleeding. Therefore, a platelet count of 115,000/ul would be identified as an abnormal finding by the nurse.