Nokea
Before beginning a newborn’s physical assessment,the nurse reviews the newborn’s medical record and sees this notation: “31 weeks’ gestation.” Considering this information the nurse determines that a physical assessment of the infant should reveal which finding?
- A. Flexion of all four extremities
- B. The ability to suck
- C. The absence of lanugo
- D. Vernix covering the infant
Correct Answer: D
Rationale: "Preterm infants (31 weeks) are covered with vernix caseosa. Flexion is minimal sucking is absent before 33 weeks and lanugo is extensive."
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What is the diameter of fetal skull that presents at vulva during normal labour:
- A. Suboccipitofrontal.
- B. Mentovertical.
- C. Suboccipitobregmatic.
- D. Occipitofrontal.
- E. Metoposterior.
Correct Answer: C
Rationale: In normal vertex presentation the suboccipitobregmatic diameter (9.5 cm) is the smallest and presents at the vulva during delivery. Other diameters are larger or associated with abnormal presentations.
The client with oligohydramnios and possible intrauterine growth restriction gives birth. The newborn’s 1-minute Apgar score was 6,and the 5-minute Apgar score is 7. Which conclusion should the nurse make from this information?
- A. A low Apgar score at 1 minute correlates with infant mortality.
- B. The 5-minute Apgar score of 7 is within normal parameters.
- C. Neurological problems are unlikely with a 5-minute score of 7.
- D. Oligohydramnios would not have affected the Apgar score.
Correct Answer: B
Rationale: A 5-minute Apgar score at or above 7 is considered normal. A low 1-minute score is not associated with mortality but a low 5-minute score is. Apgar scores are poor predictors of neurological outcomes and oligohydramnios can affect scores.
The nurse is administering surfactant via ET tube to a 48-hour-old preterm infant with respiratory distress syndrome (RDS). The father asks the nurse how this treatment will help his baby. The nurse should explain that the preterm infant is unable to produce adequate amounts of surfactant and that giving it to his baby will have what effect?
- A. Increase PaCO2 levels in the bloodstream
- B. Prevent collapse of the alveoli
- C. Decrease PaO2 levels in the bloodstream
- D. Prevent pleural effusion
Correct Answer: B
Rationale: Surfactant prevents alveolar collapse in RDS improving gas exchange decreasing PaCO2 and increasing PaO2. Pleural effusion is unrelated.
Which statement by the parents best indicates that the nurse's teaching has been effective?
- A. We'll give our child the penicillin for the full 10 days.
- B. We will keep our child at home until fully recovered.
- C. We will make sure that our child stays out of the sun with being treated.
- D. We'll notify the physician if our child has a sore throat.
Correct Answer: D
Rationale: Effective teaching about rheumatic fever emphasizes preventing recurrent streptococcal infections, which can trigger relapse. Notifying the physician about a sore throat ensures prompt treatment of potential streptococcal infections, reducing recurrence risk.
Diabetic control is important before conception to reduce the incidence of:
- A. Maternal nephropathy.
- B. Diabetic ketoacidosis.
- C. Congenital anomalies.
- D. Maternal retinopathy.
- E. C-section.
Correct Answer: C
Rationale: Preconception glycemic control in diabetes reduces the risk of congenital anomalies which are significantly increased with poor control (e.g. neural tube defects cardiac anomalies). Other complications are less directly tied to preconception control.