Nokea
A nurse notes that a baby is lying in a crib in the tonic neck position. In which of the following positions is the baby lying?
- A. One of the baby's arms and one of its legs are extended to the same side the baby's head is facing.
- B. When the baby faces straight ahead, the baby's head tilts toward one side.
- C. Both the baby's back and head are sharply arched backward and resist being moved to midline.
- D. When the baby lies prone, the baby's body arches to one side.
Correct Answer: A
Rationale: The tonic neck reflex, or fencer's position, involves the baby's arm and leg on one side extending while the opposite arm and leg flex.
You may also like to solve these questions
A 36-week-gestation client is having an amniocentesis. For which of the following reasons is the test likely being conducted?
- A. Genetic evaluation.
- B. Assessment of intrauterine growth restriction.
- C. Assessment of fetal lung maturation.
- D. Hormonal studies.
Correct Answer: C
Rationale: Amniocentesis at 36 weeks is often performed to assess fetal lung maturity before delivery.
A woman asks the nurse to recommend the best douche for use after menstruation. Which of the following responses by the nurse is appropriate?
- A. Tap water with white vinegar is most refreshing and least allergenic.'
- B. It is really best for women not to douche.'
- C. Any of the over-the-counter douches is satisfactory.'
- D. It is best to douche during menstruation rather than after it is over.'
Correct Answer: B
Rationale: Douching can disrupt the natural vaginal flora and increase the risk of infections, so it is generally not recommended.
A client who is 18 weeks’ gestation has been diagnosed with a hydatiform mole (gestational trophoblastic disease). In addition to vaginal loss, which of the following signs/symptoms would the nurse expect to see?
- A. Hyperemesis and hypertension.
- B. Diarrhea and hyperthermia.
- C. Polycythemia.
- D. Polydipsia.
Correct Answer: A
Rationale: Hyperemesis and hypertension are common symptoms of a hydatiform mole due to the excessive production of hCG.
A pregnant woman is complaining of ptyalism. The nurse should teach the woman to try which of the following self-care measures?
- A. Use an astringent mouthwash.
- B. Elevate her legs frequently.
- C. Eat high-fiber foods.
- D. Void when the urge is felt.
Correct Answer: A
Rationale: Ptyalism, or excessive salivation, can be managed with astringent mouthwash to reduce saliva production.
The nurse is providing education to a patient at 16 weeks' gestation who is undecided about consenting to the quad screen. How can the nurse explain the purpose of the quad screen to the patient?
- A. It indicates the risk of the fetus for heart defects.
- B. It indicates the risk of the fetus for neural tube defects.
- C. It indicates the risk of the fetus for neural tube defects and chromosome abnormalities.
- D. It indicates the risk of the fetus for chromosome abnormalities.
Correct Answer: C
Rationale: The correct answer is C because the quad screen is a prenatal screening test that assesses the risk of the fetus for neural tube defects and chromosome abnormalities. At 16 weeks' gestation, this test helps identify potential issues early on, allowing for further diagnostic testing and appropriate interventions if needed. Choice A is incorrect because the quad screen does not specifically target heart defects. Choice B is incorrect as the quad screen does not solely focus on neural tube defects. Choice D is incorrect because the quad screen assesses both neural tube defects and chromosome abnormalities, not just chromosome abnormalities alone. Therefore, choice C is the most comprehensive and accurate explanation of the purpose of the quad screen for the patient at 16 weeks' gestation.