Nokea
Blood flow connection between the systemic, aorta, pulmonary blood flow, and pulmonary artery is which fetal shunt?
- A. ductus venosus
- B. foramen ovale
- C. ductus arteriosus
- D. foramen venosus
Correct Answer: C
Rationale: The ductus arteriosus connects the pulmonary artery to the descending aorta, allowing most fetal blood to bypass the lungs.
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A student nurse is verbalizing disappointment in a new mothers seeming lack of interest in her newborn baby. The student complains to the registered nurse that the mother just wants to sleep and have someone else care for the infant. What response by the registered nurse is best?
- A. Assess closely; we may need to call social work.
- B. Dont judge other people until you have had a baby.
- C. The mother may be completely exhausted from the childbirth experience.
- D. We have to accept that everyones experience is different.
Correct Answer: C
Rationale: After a long and possibly difficult birth
What organization developed the CJMM?
- A. ACOG
- B. ANA
- C. AWHONN
- D. NCSBN
Correct Answer: D
Rationale: The National Council of State Boards of Nursing (NCSBN) developed the Clinical Judgment Measurement Model (CJMM).
The nurse is assigned to the postpartum room of a 12-hour-old neonate, and the EHR has a task reminder prompting the nurse to complete a Brazelton assessment on the newborn. Why is this not appropriate?
- A. This newborn has been born to a person who is placing the infant up for adoption.
- B. This newborn has been born to a person who birthed by cesarean section.
- C. This newborn is only 12 hours old.
- D. This newborn is experiencing pathologic jaundice.
Correct Answer: C
Rationale: The Brazelton Neonatal Behavioral Assessment Scale is typically performed after 24–48 hours of life.
The nurse is evaluating the involution of a woman who is 3 days post partum. Which of the following finding would the nurse evaluate as normal?
- A. Fundus 1 cm above the umbilicus, lochia rosa.
- B. Fundus 2 cm above the umbilicus, lochia alba.
- C. Fundus 2 cm below the umbilicus, lochia rubra.
- D. Fundus 3 cm below the umbilicus, lochia serosa.
Correct Answer: D
Rationale: By day 3, the fundus should descend to 3 cm below the umbilicus, and lochia should transition to serosa.
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.