Nokea
Calculating from the date of the mother’s last menstrual period,the nurse determines that her newborn’s gestational age is 40 weeks. Which normal findings should the nurse expect when assessing this newborn at birth? Select all that apply.
- A. Hypertonic flexion of all extremities.
- B. Sole creases on the anterior two-thirds of the sole.
- C. Well-defined incurving of the entire ear pinna.
- D. Presence of a prominent clitoris.
- E. Infant is able to support the head momentarily when pulled to a sitting position.
Correct Answer: A,C,E
Rationale: Full-term newborns (40 weeks) exhibit hypertonic flexion well-defined ear pinna incurving and momentary head support. Sole creases over two-thirds indicate ~37 weeks and a prominent clitoris is seen at 30–32 weeks.
You may also like to solve these questions
Perinatal mortality rate is defined as:
- A. Number of perinatal deaths per thousand live births and still births.
- B. Deaths in the first week after birth.
- C. All still births plus deaths in the first week after birth.
- D. Deaths from age 7 days the 27 completed days of life.
- E. Deaths in first week after birth.
Correct Answer: A
Rationale: Perinatal mortality rate is defined as the number of stillbirths and deaths in the first week of life per 1000 live births and stillbirths capturing early neonatal and late fetal losses.
Which findings by the nurse best indicate that the child is experiencing diabetic ketoacidosis? Select all that apply.
- A. Blood glucose level of 120 mg/dL
- B. Fruity-smelling breath
- C. Pale-colored face
- D. Excessive perspiration
- E. Deep, rapid breathing
- F. Dry, flushed skin
Correct Answer: B,E,F
Rationale: Diabetic ketoacidosis (DKA) is characterized by hyperglycemia (blood glucose typically >250 mg/dL, so 120 mg/dL is incorrect), fruity-smelling breath due to acetone, deep and rapid breathing (Kussmaul respirations) to compensate for acidosis, and dry, flushed skin due to dehydration.
A 24 years old G2P1A0 had last menstrual period 9 weeks ago. She presents with bleeding and passage of tissues pervaginum. Bleeding is associated with lower abdominal pain. The most likely diagnosis is:
- A. Threatened abortion.
- B. Inevitable abortion.
- C. Incomplete abortion.
- D. Twin pregnancy.
- E. Ectopic pregnancy.
Correct Answer: C
Rationale: Incomplete abortion occurs when products of conception are partially expelled leading to vaginal bleeding passage of tissue and lower abdominal pain as seen in this case. Threatened abortion involves bleeding without tissue passage or cervical dilation. Inevitable abortion implies an open cervix but not necessarily tissue passage. Ectopic pregnancy typically presents with unilateral pain and no tissue passage. Twin pregnancy is unrelated to these symptoms.
Which instruction should the nurse include when teaching the parents about the administration of oral penicillin to their child?
- A. Give the medication with a full glass of orange juice.
- B. Give the medication after a large meal.
- C. Continue the medication even if the child develops a rash.
- D. Continue the medication for the full course of therapy.
Correct Answer: D
Rationale: Completing the full course of penicillin therapy eradicates the infection and prevents recurrence or resistance, especially for streptococcal infections.
Which intervention is most appropriate initially for an 8-year-old child who selects the fourth face on the Wong-Baker FACES Pain Rating Scale?
- A. Take no action; the child is pain-free.
- B. Provide diversional activities to relieve the child's pain.
- C. Document findings, and recheck the child later.
- D. Give the prescribed analgesic to relieve the pain.
Correct Answer: D
Rationale: The fourth face on the Wong-Baker FACES Pain Rating Scale indicates moderate to severe pain, requiring administration of a prescribed analgesic for effective pain relief.