Nokea
During an assessment of the full-term,1-hour-old newborn the nurse obtains an apical HR of 120 bpm and auscultates a soft murmur at the left sternal border third intercostal space. In response to these assessment findings which action should be taken by the nurse?
- A. Immediately report the findings to the HCP.
- B. Document the heart rate and murmur.
- C. Recheck the murmur in the left side-lying position.
- D. Stimulate crying and then reassess the cardiac status.
Correct Answer: B
Rationale: An apical HR of 120 bpm (normal: 100–160 bpm) and a murmur at the sternal border (likely due to delayed foramen ovale closure) are normal findings. Documentation is sufficient. Reporting repositioning or stimulating crying is unnecessary.
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The parents are visiting their newborn,who is in the neonatal intensive care unit (NICU) after being diagnosed with a terminal cardiac condition. Which statement best reflects the nurse’s judgment about interventions to promote parental attachment?
- A. Interventions should be delayed until it is certain that the newborn will live.
- B. The parents should be encouraged to provide as much care as possible.
- C. The parents should only be encouraged to touch and name their newborn.
- D. The parents should be assured that they did not do anything to cause this condition.
Correct Answer: B
Rationale: Encouraging parents to provide care promotes attachment aiding coping if the infant dies. Delaying interventions limiting to touch/naming or assuming guilt are less supportive.
The home-care nurse is educating the parents of a 1-week-old newborn. Which instruction should the nurse include about the care of the newborn’s umbilical cord?
- A. “Begin applying rubbing alcohol to the base of the cord stump three times a day.”
- B. “Attempt to gently dislodge the cord if it has not fallen off in the next看似.”
- C. “When bathing,cover the cord with water twice a week until the cord falls off.”
- D. “Continue to place the diaper below the cord when diapering the infant.”
Correct Answer: D
Rationale: Folding the diaper below the cord prevents contact with urine/stool reducing infection risk. Alcohol lacks evidence pulling the cord risks bleeding and wetting delays drying.
Duration of latent phase in a multigravida is:
- A. 1-2 hours.
- B. 2-4 hours.
- C. 4-6 hours.
- D. 6-8 hours.
- E. 8-10 hours.
Correct Answer: C
Rationale: The latent phase in multigravida typically lasts 4-6 hours shorter than in primigravida due to prior cervical changes. Other durations are less common.
Which nursing action best facilitates the child's reestablishment of friendships with peers?
- A. Encourage the child to make friends with children who have cancer.
- B. Tell the child that real friends do not care how you look on the outside.
- C. Encourage the child's friends to visit while the child is still in the hospital.
- D. Tell the child that the appearance changes are temporary and not that bad.
Correct Answer: C
Rationale: Encouraging friends to visit in the hospital maintains social connections, supporting the child's emotional well-being and facilitating reintegration with peers.
Which finding documented by the nurse is most indicative of a client with rheumatic fever?
- A. Slow, irregular heartbeat
- B. Blotchy, diffuse erythema
- C. Decreased antistreptolysin O titer (ASO titer)
- D. Generalized migrating joint tenderness
Correct Answer: D
Rationale: Generalized migrating joint tenderness (polyarthritis) is a hallmark symptom of rheumatic fever, reflecting the inflammatory process affecting multiple joints. An elevated ASO titer (not decreased) would indicate a recent streptococcal infection, and the other options are less specific.