Dubowitz criteria to assess gestational age include:
- A. Skin colour
- B. Breast tissue
- C. Popliteal angle
- D. Moro reflex
Correct Answer: B
Rationale: Breast tissue is one of the criteria used in the Dubowitz assessment to estimate gestational age. Skin colour, popliteal angle, and Moro reflex are not part of the Dubowitz criteria.
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A female client enters the clinic and insists on being seen. She is weak, nervous, and reports a racing heart beat and recent weight loss of 15 pounds. After ruling out substance withdrawal, the healthcare provider suspects hyperthyroidism and admits her for further testing. Which action should the nurse implement?
- A. Begin preparing client for thyroidectomy procedure
- B. Space the client's care to provide periods of rest
- C. Assess the client for hyperactive bowel sounds
- D. Provide warm blankets to prevent heat loss
Correct Answer: B
Rationale: Rest is important for managing symptoms of hyperthyroidism, which can be exacerbated by stress and activity.
While assessing a newborn with respiratory distress, the nurse auscultates a machine-like heart murmur. Other findings are a wide pulse pressure, periods of apnea, increased PaCO2, and decreased PO2. The nurse suspects that the newborn has:
- A. Pulmonary hypertension
- B. Patent ductus arteriosus (PDA)
- C. Ventricular septal defect (VSD)
- D. Bronchopulmonary dysplasia
Correct Answer: B
Rationale: A machine-like murmur is the hallmark of a PDA.
Pregnancy is contraindicated in mothers with
- A. pulmonary hypertension
- B. ventricular septal defects
- C. prosthetic valves
- D. atrial septal defects
Correct Answer: A
Rationale: Pregnancy is contraindicated in severe pulmonary hypertension and unoperated cyanotic congenital heart disease.
The definition of hypertension in children is
- A. average systolic blood pressure (SBP) and/or diastolic BP that is ≥95th percentile for age, sex, on ≥2 occasions
- B. average systolic blood pressure (SBP) and/or diastolic BP that is ≥95th percentile for age, sex, and height on ≥2 occasions
- C. average systolic blood pressure (SBP) and/or diastolic BP that is ≥95th percentile for age, sex, and height on ≥3 occasions
- D. average systolic blood pressure (SBP) and/or diastolic BP that is ≥90th percentile for age, sex, and height on ≥3 occasions
Correct Answer: C
Rationale: Hypertension in children is defined as BP ≥95th percentile for age, sex, and height on ≥3 occasions.
The parent of a 1-year-old child with tetralogy of Fallot asks the nurse, “Why do my child’s fingertips look like that?†On what understanding does the nurse base a response?
- A. Clubbing occurs as a result of untreated congestive heart failure.
- B. Clubbing occurs as a result of a left-to-right shunting of blood.
- C. Clubbing occurs as a result of decreased cardiac output.
- D. Clubbing occurs as a result of chronic hypoxia.
Correct Answer: D
Rationale: Clubbing of the fingers develops in response to chronic hypoxia.