Nokea
At 28 weeks gestation, a woman enters the hospital in preterm labor and receives atocolytic medication to stop labor. Which assessment findings should be reported immediately to the physician?
- A. Fetal heart rate averaging 160 beats/min
- B. Irregular contractions every 15-20 minutes that last 30 seconds before stopping
- C. Maternal temperature 98.8 degrees F, pulse 84, respiratory rate 22, BP 130/70
- D. Ferning pattern of vaginal discharge under a microscope
Correct Answer: D
Rationale: The correct answer is D - Ferning pattern of vaginal discharge under a microscope. This finding indicates rupture of membranes which can lead to infection and necessitates immediate medical attention to prevent harm to the fetus and mother. A: Fetal heart rate of 160 bpm is within normal range. B: Irregular contractions every 15-20 minutes are not indicative of active labor. C: Maternal vital signs are within normal limits and do not pose an immediate threat.
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Immediately after birth, the nurse places the newborn under a radiant warmer. Which is the primary rationale for the nurse's action?
- A. To facilitate an efficient means of thermoregulation
- B. To facilitate initial assessment by the nurse
- C. To permit the use of the cardiac monitor
- D. To permit close observation by the family members
Correct Answer: A
Rationale: The correct answer is A: To facilitate an efficient means of thermoregulation. Placing the newborn under a radiant warmer helps prevent hypothermia by maintaining the baby's body temperature. Newborns have difficulty regulating their own body temperature initially, so the radiant warmer provides a controlled environment to keep them warm. Choice B is incorrect because the primary reason is not for assessment but for thermoregulation. Choice C is incorrect as a cardiac monitor is not typically needed immediately after birth. Choice D is incorrect as the primary focus is on the newborn's well-being, not family observation.
A women in her first trimester contracts rubella. How is the fetus likely to be affected?
- A. Reproductive and urinary defects
- B. Heart defects and cataracts
- C. Spinal cord and skeletal defects
- D. Polydactyly and club feet
Correct Answer: B
Rationale: The correct answer is B: Heart defects and cataracts. Rubella infection during the first trimester can lead to congenital rubella syndrome, causing heart defects and cataracts in the fetus. Rubella affects organ development during this critical period. Choice A is incorrect as rubella does not typically cause reproductive and urinary defects. Choice C is incorrect because rubella does not usually result in spinal cord and skeletal defects. Choice D is incorrect as polydactyly and club feet are not typical manifestations of rubella infection during pregnancy.
A 38 week gestation newborn weighs 4020 grams, is sluggish, and has limp muscle tone. The baby experienced a broken clavicle during delivery. Based on this information, which can the nurse conclude about the baby?
- A. Neonatal abstinence symptoms
- B. Large for gestational age
- C. Congenital cardiac defect
- D. Respiratory depression
Correct Answer: B
Rationale: The correct answer is B: Large for gestational age. A newborn weighing 4020 grams at 38 weeks is considered large for gestational age. The sluggishness and limp muscle tone can be attributed to the baby's size, which can make movement more challenging. The broken clavicle could have occurred during delivery due to the baby's size and the forces involved. Neonatal abstinence symptoms (choice A) typically present with irritability, tremors, and poor feeding, not sluggishness. Congenital cardiac defects (choice C) usually manifest with cyanosis, tachypnea, and poor feeding. Respiratory depression (choice D) is characterized by poor respiratory effort, not sluggishness and limp muscle tone.
Which is a major difference in the clinical manifestation of adolescents with anorexia nervosa compared to bulimia?
- A. Binge eating
- B. Purging
- C. Body image distortion
- D. Decreased self esteem
Correct Answer: C
Rationale: The major difference between adolescents with anorexia nervosa and those with bulimia is body image distortion. Clients with anorexia see themselves as being overweight no matter how underweight they become. Clients with bulimia see their weight realistically but have psychological problems that manifest in an eating disorder. Both disorders may involve binge eating and purging, but body image perception is a distinguishing factor.
A nurse is preparing to take a rectal temperature on a 7-month-old infant. Which of the following should the nurse keep in mind when preparing to take the temperature?
- A. A well-lubricated thermometer tip should be inserted a maximum of 2.5 in into the rectum.
- B. A rectal temperature of 99.6° F is equal to an oral temperature of 97.7° F.
- C. Infants should have temperatures taken rectally for accuracy and thermoregulation.
- D. Mercury thermometers are the thermometers of choice to obtain the rectal temperature, holding it in place for 4 min.
Correct Answer: B
Rationale: Correct Answer: B
Rationale: The correct answer is B because rectal temperatures are typically 1.5-2°F higher than oral temperatures due to the body's core temperature being higher internally. This conversion is essential in accurately interpreting the infant's rectal temperature.
Summary of other choices:
A: Incorrect. The maximum insertion depth for a rectal thermometer in infants is 1 inch, not 2.5 inches.
C: Incorrect. Rectal temperatures are not the only accurate method for infants; axillary or temporal artery thermometers are also reliable.
D: Incorrect. Mercury thermometers are no longer recommended due to the risk of mercury exposure, and the time required to obtain a rectal temperature is typically shorter.