Nokea
A patient calls and says she used her diaphragm on Saturday night at 8:00 p.m., again on Sunday morning at 2:00 a.m., and again at 8:00 a.m. She is wondering when she can safely remove it while still having effective contraception. What is the nurse’s best response?
- A. 10:00 a.m. Sunday
- B. 2:00 p.m. Sunday
- C. 10:00 p.m. Sunday
- D. 8:00 a.m. Monday
Correct Answer: D
Rationale: In general, a diaphragm should be left in place for at least 6 hours after intercourse but no more than 24 hours. Based on the patient's usage times on Saturday night at 8:00 p.m., Sunday morning at 2:00 a.m., and Sunday morning at 8:00 a.m., she can safely remove the diaphragm on Monday morning at 8:00 a.m. This ensures she has used it for the necessary timeframe for effective contraception.
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A woman's temperature has just risen 0.4°F and will remain elevated during the remainder of her cycle. She expects to menstruate in about 2 weeks. Which of the following hormones is responsible for the change?
- A. Progesterone
- B. Follicle stimulating hormone
- C. Luteinizing hormone
- D. Estrogen
Correct Answer: D
Rationale: The hormone responsible for the increase in body temperature prior to menstruation is estrogen. Estrogen is the primary female sex hormone that plays a key role in regulating the menstrual cycle. Around the time of ovulation, estrogen levels peak, which can lead to a slight rise in body temperature. This increase in temperature is known as the "estrogenic temperature shift" and is a normal part of the menstrual cycle. The rise in body temperature indicates that ovulation has occurred and that a woman is approaching her fertile window. Estrogen also helps prepare the uterine lining for pregnancy and plays a role in many other reproductive functions.
Which newborn reflex is assessed by stroking the cheek?
- A. Startle reflex
- B. Rooting reflex
- C. Babinski reflex
- D. Sucking reflex
Correct Answer: B
Rationale: The rooting reflex is observed when stroking the cheek, helping the newborn find the breast for feeding.
What is the most appropriate action for a nurse when a newborn has jaundice on the second day of life?
- A. Increase fluid intake of the mother
- B. Phototherapy
- C. Monitor bilirubin levels
- D. Refer to a pediatric specialist
Correct Answer: B
Rationale: Phototherapy helps treat jaundice by breaking down bilirubin.
Which of the following is an abnormal finding upon
- A. To monitor hydration status physical examination of an infant?
- B. To reduce the risk of bladder injury
- C. Anterior fontanel that has a diamond-shaped open
- D. To prevent the patient from urinating during space surgery
Correct Answer: D
Rationale: The abnormal finding listed in option D, "To prevent the patient from urinating during space surgery," stands out from the rest of the options provided. This is because during space surgery, it is not necessary or appropriate to prevent the patient from urinating; rather, it is essential to focus on the surgical procedure and the patient's safety in a space environment. The other options focus on normal or abnormal physical examination findings in infants, such as the hydration status, fontanel appearance, suture line spacing, ear positioning, and uterus displacement.
The nurse assess that a newborn is in respiratory distress when the infant exhibits:
- A. Apnea, grunting, wheezing, and crackles
- B. Wheezing, cyanosis, hiccups, and crackles
- C. Cyanosis, retraction, wheezing, and hiccups
- D. Tachypnea, retraction, grunting, and cyanosis
Correct Answer: D
Rationale: In newborns, respiratory distress can present with various signs and symptoms. The combination of tachypnea (rapid breathing), chest retractions (visible sinking of the skin in between or below the ribs with each breath), grunting (sound made during expiration), and cyanosis (blue discoloration of the skin and mucous membranes) are indicative of respiratory distress in a newborn. These signs suggest that the newborn is having difficulty breathing and may require immediate medical attention. It is essential to recognize and address respiratory distress promptly to ensure the well-being of the newborn.