Nokea
At birth, a newborn weighed 6 pounds, 12 ounces. Three days later, the newborn weighs 5 pounds, 10 ounces. What conclusion should the nurse draw regarding this newborn's weight?
- A. This weight loss is within normal limits.
- B. This weight gain is within normal limits.
- C. This weight loss is excessive.
- D. This weight gain is excessive.
Correct Answer: C
Rationale: The correct answer is C: This weight loss is excessive. The newborn's weight decreased from 6 lbs 12 oz to 5 lbs 10 oz in just three days, indicating a significant loss. A newborn typically loses around 5-10% of their birth weight in the first few days. This weight loss exceeds the expected range, suggesting potential issues like inadequate feeding or dehydration. Choices A and B are incorrect because the weight loss is not within normal limits, and weight gain is not observed. Choice D is incorrect as there is no weight gain, let alone excessive weight gain.
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The nurse determines the gestational age of an infant to be 40 weeks. Which characteristics are most likely to be observed? (Select all that apply.)
- A. Testes are pendulous, and the scrotum has deep rugae
- B. Plantar creases over entire sole
- C. Lanugo abundant over shoulders and back
- D. Vernix well distributed over entire body
Correct Answer: A
Rationale: Full-term infants typically exhibit pendulous testes, deep scrotal rugae, and plantar creases over the entire sole. Lanugo is usually minimal, and vernix tends to be localized rather than widespread.
What does the nursing process describe?
- A. what nurses do
- B. how nurses think
- C. where nurses provide care
- D. who nurses care for
Correct Answer: A
Rationale: The nursing process outlines the systematic approach to providing patient care, focusing on what nurses do—assess, diagnose, plan, implement, and evaluate.
Which diagnosis is most appropriate for a newborn who has not voided within 24 hours after delivery?
- A. Hypovolemia related to insufficient fluid intake
- B. Altered growth and development related to gestational age of 36 weeks
- C. Altered nutrition, less than body requirements related to failure to properly latch onto the breast
- D. Constipation related to failure to pass a meconium stool and possible bowel obstruction
Correct Answer: A
Rationale: The correct answer is A: Hypovolemia related to insufficient fluid intake. In a newborn, the inability to void within 24 hours after birth can indicate dehydration and hypovolemia due to insufficient fluid intake. Newborns need to pass urine within the first 24 hours of life to show adequate hydration. Altered growth and development (choice B) is not relevant to the immediate concern of no voiding. Altered nutrition (choice C) is unlikely to cause the absence of urine output. Constipation (choice D) is less likely in a newborn and is not the primary concern when a newborn fails to void.
An infant at term was born at 0105 hours. The nurse is developing a plan of care for the newborn. During which time range will the nurse plan on performing the assessment to determine a Ballard score?
- A. 0115 to 0130
- B. 0200 to 0600
- C. 1400 to 1800
- D. 2000 to 2300
Correct Answer: B
Rationale: The correct answer is B (0200 to 0600) because the Ballard score is typically assessed within the first 12-24 hours of life. Given that the infant was born at 0105 hours, the nurse should plan on performing the assessment between 0200 to 0600. This time frame falls within the recommended window for assessing the Ballard score accurately. Choices A, C, and D are incorrect because they fall outside the optimal time range for conducting the assessment. Option A (0115 to 0130) is too soon after birth, and options C (1400 to 1800) and D (2000 to 2300) are too late for the initial assessment as per standard practice.
The nurse notices that a 6-hour-old newborn patient's urethral opening is on the dorsal side of the penis. The nurse knows that this is called what?
- A. hypospadias
- B. epispadias
- C. phimosis
- D. unispadias
Correct Answer: B
Rationale: The correct answer is B: epispadias. In epispadias, the urethral opening is located on the dorsal side of the penis. This condition is a congenital anomaly where the urethra fails to fully close during fetal development. Hypospadias (choice A) is when the urethral opening is on the underside of the penis. Phimosis (choice C) is the inability to retract the foreskin. Unispadias (choice D) is not a recognized medical term. Therefore, the nurse correctly identifies the condition as epispadias due to the specific presentation of the urethral opening on the dorsal side of the penis in the 6-hour-old newborn patient.