Nokea
An infant had four wet diapers during the 8-hour shift. The weight of a dry diaper is 15 g. The four wet diapers weighed 30 g, 24 g, 21 g, and 25 g. What amount in milliliters should the nurse record for the total 8-hour urine? _______ mL (Record your answer as a whole number.)
Correct Answer: 40
Rationale: Subtract dry diaper weight (15 g): 30–15=15 g 24–15=9 g 21–15=6 g 25–15=10 g. Total: 15+9+6+10=40 g equaling 40 mL urine output.
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23 years old primigravida presents to you at fourteen weeks of gestation. She is concerned about normality of fetus. At what time you will advice her detailed fetal anomaly scan:
- A. 22-24 weeks.
- B. 14-16 weeks.
- C. 18-22 weeks.
- D. 10-14 weeks.
- E. 24-28 weeks.
Correct Answer: C
Rationale: A detailed fetal anomaly scan is typically performed between 18-22 weeks of gestation as this is the optimal time to visualize fetal anatomy clearly. Earlier scans (10-14 weeks) are for nuchal translucency and later scans may miss the window for detailed structural assessment.
Which client symptoms documented by the nurse best indicate that the child is having a hypoglycemic reaction? Select all that apply.
- A. The child complains of being thirsty.
- B. The child's breathing is labored and prolonged.
- C. The child is more hungry than usual.
- D. The child complains of feeling shaky.
- E. The child reports feeling light-headed.
- F. The child states his or her heart is racing.
Correct Answer: D,E,F
Rationale: Hypoglycemia causes shakiness, light-headedness, and tachycardia due to low blood glucose triggering the sympathetic nervous system. Thirst and hunger are less specific, and labored breathing is unrelated.
Which diversional activity suggested by the nurse is most appropriate for the child during the acute phase of rheumatic fever?
- A. Playing with action figures
- B. Playing video games
- C. Reading an adventure story
- D. Pounding wooden pegs with a mallet
Correct Answer: C
Rationale: During the acute phase of rheumatic fever, the child is on bed rest to reduce cardiac workload. Reading an adventure story is a quiet, non-physically demanding activity appropriate for a 7-year-old, promoting rest while keeping the child engaged.
The nurse is caring for a preterm infant with respiratory distress syndrome (RDS). Which intervention should the nurse implement to maximize the infant’s respiratory status?
- A. Check blood glucose levels every 4 hours.
- B. Cool and humidify all inspired gases.
- C. Weigh the infant every other day.
- D. Place the infant in a prone position.
Correct Answer: D
Rationale: The prone position improves oxygenation in collapsed alveoli for RDS infants with cardiorespiratory monitoring. Glucose checks cold gases and infrequent weighing don’t aid respiration.
The nurse correctly advises the adolescent that the brace has to be worn during which time period?
- A. At all times except when bathing
- B. At least 8 hours each day
- C. At night while sleeping
- D. At all times, without exception
Correct Answer: A
Rationale: The Milwaukee brace is typically worn 23 hours a day, except during bathing, to effectively correct scoliosis by maintaining spinal alignment.