Nokea
A woman delivers a 3,250 g neonate at 42 weeks' gestation. Which physical finding is expected during an examination if this neonate?
- A. Abundant lanugo
- B. Absence of sole creases
- C. Breast bud of 1-2 mm in diameter
- D. Leathery, cracked, and wrinkled skin
Correct Answer: D
Rationale: A neonate born at 42 weeks' gestation, also known as post-term, is expected to have skin that appears leathery, cracked, and wrinkled due to prolonged exposure to the amniotic fluid in utero. This is a common physical finding in post-term neonates due to the decreased amount of vernix caseosa and amniotic fluid present on the skin at birth. Abundant lanugo (fine hair), absence of sole creases, and breast bud development are more commonly seen in preterm or term newborns, rather than post-term newborns.
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A 5 years old boy presents with joint swelling after minor trauma, mother gives history of prolonged bleeding from circumcision site. His platelets count is 170000, PT is 10 seconds and APTT is 60 seconds. What is most likely the diagnosis?
- A. Idiopathic thrombocytopenic purpura
- B. Platelets function defect
- C. Von Willebrand disease
- D. Hemophilia
Correct Answer: D
Rationale: Hemophilia is characterized by prolonged APTT with normal platelet count and PT, indicating a coagulation factor deficiency.
What is the most important postoperative instruction the nurse must give a client who has just returned from the operating room after receiving a subarachnoid block?
- A. "Avoid drinking liquids until the gag reflex returns."
- B. "Avoid eating milk products for 24 hours."
- C. "Notify a nurse if you experience blood in your urine."
- D. "Remain supine for the time specified by the physician."
Correct Answer: D
Rationale: After receiving a subarachnoid block, the client may experience a sudden drop in blood pressure that can lead to complications such as dizziness or fainting upon standing. Therefore, it is crucial for the client to remain in a supine position for the duration specified by the physician to allow for proper monitoring and management of any potential postoperative complications. This instruction helps prevent the occurrence of hypotension and other adverse effects by allowing adequate time for the block to wear off and for the body to adjust to changes in blood pressure. It also ensures the safety and well-being of the client during the immediate postoperative period.
Which is an important consideration when the nurse is discussing enuresis with the parents of a young child?
- A. Enuresis is more common in girls than in boys.
- B. Enuresis is neither inherited nor has a familial tendency.
- C. Organic causes that may be related to enuresis should be considered first.
- D. Psychogenic factors that cause enuresis persist into adulthood.
Correct Answer: C
Rationale: An important consideration when the nurse is discussing enuresis with the parents of a young child is that organic causes related to enuresis should be considered first. Enuresis, or bedwetting, can have various causes including physical issues like urinary tract infections, constipation, or structural abnormalities. It is essential to rule out any underlying medical conditions before addressing behavioral or psychological factors. By focusing on organic causes first, healthcare providers can ensure that the child receives appropriate evaluation and treatment, leading to better outcomes.
What is an important consideration for the nurse who is communicating with a very young child?
- A. Speak loudly, clearly, and directly.
- B. Use transition objects, such as a doll.
- C. Disguise own feelings, attitudes, and anxiety.
- D. Initiate contact with child when parent is not present.
Correct Answer: B
Rationale: When communicating with a very young child, using transition objects, such as a doll, can help create a sense of familiarity, comfort, and security. These objects can serve as a bridge for the child to express themselves and can also provide a point of reference for the nurse to better understand the child's perspective. Additionally, transition objects can help the child feel more at ease during interactions with healthcare providers, making the communication process smoother and more effective.
Which of the ff nursing interventions is taken as a precautionary measure if shock develops when a client with a spinal cord injury is hospitalized?
- A. An IV line is inserted to provide access to a vein
- B. The head and back are immobilized mechanically with a cervical collar and back support
- C. Traction with weights and pulleys is applied
- D. A turning frame is used EMERGENCY AND DISASTER NURSING SITUATION: A group of high school teenagers went camping to Sohoton this summer for one week. You are the nurse assigned to this camp. For the first three days, you were busy with several emergencies.
Correct Answer: A
Rationale: In a hospital setting, if shock develops in a client with a spinal cord injury, one of the initial nursing interventions as a precautionary measure is to establish intravenous access by inserting an IV line. This is important for administering fluids, medications, and blood products promptly to help stabilize the client's condition. IV access is crucial in managing shock to ensure proper fluid resuscitation and support the circulatory system to maintain adequate perfusion to vital organs. It also allows for continuous monitoring of the client's hemodynamic status, electrolyte levels, and responses to interventions. Therefore, inserting an IV line is a critical nursing intervention in addressing shock in clients with spinal cord injuries to promote timely and effective management.