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A nurse is talking to the parents of a 3-year-old child about water safety precautions. Which of the following statements made by the parents indicates a need for clarification?
- A. We keep the toilet seat down at all times.
- B. We don't answer the phone during bath time.
- C. We empty all buckets filled with water.
- D. We have our child in swimming lessons.
Correct Answer: D
Rationale: The correct answer is D because enrolling a 3-year-old child in swimming lessons does not necessarily prevent drowning incidents. It is crucial for parents to understand that even with swimming lessons, active supervision around water is essential to prevent accidents. Keeping the toilet seat down (A), avoiding distractions during bath time (B), and emptying buckets filled with water (C) are all important water safety precautions to prevent drowning incidents. Swimming lessons are beneficial, but they should not replace vigilant supervision.
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At 10 weeks gestation, a primigravida asks the nurse what is occurring developmentally with her baby. Which response by the nurse is correct?
- A. The skin is wrinkled and fat is being formed.
- B. The eyelids are open and he can see.
- C. The kidneys are making urine.
- D. The heart is being developed.
Correct Answer: C
Rationale: Correct Answer: C - The kidneys are making urine.
Rationale: At 10 weeks gestation, the kidneys of the developing fetus begin to form and function, producing urine. This is a crucial milestone in fetal development as it indicates proper organ formation and functionality. The formation of urine by the kidneys plays a significant role in maintaining the amniotic fluid levels and supporting overall fetal growth and development.
Summary of other choices:
A: The skin is wrinkled and fat is being formed - Incorrect. Skin and fat formation typically occur later in gestation, not at 10 weeks.
B: The eyelids are open and he can see - Incorrect. Eye development is still in progress at 10 weeks, and the eyelids remain fused.
D: The heart is being developed - Incorrect. While the heart is forming at 10 weeks, it is not the most accurate response to the question posed by the primigravida.
A 17-year-old client delivered her first baby 8 hours ago. Which of the following is an indication that appropriate bonding is occurring? The client:
- A. makes eye contact with the baby.
- B. wonders why the baby cries so much.
- C. asks the nurse to help change the baby's diaper.
- D. asks the nurse if the baby is cute.
Correct Answer: A
Rationale: The correct answer is A: makes eye contact with the baby. This indicates appropriate bonding as eye contact fosters emotional connection and attachment between mother and baby. It shows the mother is engaging with her child, seeking to establish a bond. Choice B suggests lack of understanding of infant communication, choice C indicates practical caregiving rather than emotional bonding, and choice D focuses on the baby's appearance rather than emotional connection.
A nurse is performing a physical assessment of a newborn. Which of the following clinical findings should the nurse expect? (Select all that apply).
- A. Heart Rate 154/min
- B. Axillary temperature 96.8 F
- C. Respiratory rate 58/min
- D. Length 43 cm (16.9in)
Correct Answer: A,B,C,D
Rationale: The correct answer is A, B, C, and D.
1. Heart rate of 154/min is expected in a newborn, indicating normal cardiac function.
2. Axillary temperature of 96.8 F is within the normal range for a newborn.
3. Respiratory rate of 58/min is expected due to the newborn's immature respiratory system.
4. Length of 43 cm (16.9 in) falls within the normal range for a newborn's size.
Incorrect choices are not applicable due to lack of details, but in general, incorrect options would have included values outside the normal range for a newborn's physical assessment.
Which of the following approaches is the most accurate way to measure the heart rate of a 10-month-old infant?
- A. "Apical"'
- B. "Radial"'
- C. "Ulna"'
- D. "Brachial"'
Correct Answer: A
Rationale: The correct answer is A: "Apical." This method involves placing the stethoscope over the apex of the heart to directly listen to the heart sounds. In infants, especially 10-month-olds, the apical pulse is more accurate as it allows for a direct assessment of the heart rate without interference from other factors like peripheral pulses. The apical pulse is easier to locate in infants due to their smaller chest size and thinner chest walls. Choices B, C, and D (Radial, Ulna, and Brachial) are incorrect for measuring heart rate in infants as they involve peripheral pulse sites which may not provide an accurate representation of the heart rate due to various factors like weak pulses or difficulty in palpating them accurately in infants.
The nurse conducting a physical assessment notes that a 1-day-old newborn with dark skin has a bluish-gray discoloration over the lower back, the buttocks, and the scrotum. How should this assessment finding be documented?
- A. Extensive bruising
- B. Mongolian spots
- C. Nevus flammeus
- D. Acrocyanosis
Correct Answer: B
Rationale: The correct answer is B: Mongolian spots. This finding is common in newborns with dark skin and appears as bluish-gray discoloration in areas like the lower back, buttocks, and scrotum. Mongolian spots are benign and typically fade over time. Extensive bruising (A) would present differently and usually indicates trauma. Nevus flammeus (C) refers to a port-wine stain, which is a different type of birthmark. Acrocyanosis (D) is a condition characterized by bluish discoloration of the extremities due to poor circulation, not related to the described finding.