Nokea
During the newborn admission assessment, the nurse palpates the newborn's scrotum and does not feel the testicles. Which assessment technique should the nurse perform next to verify the absence of testes?
- A. Observe the urethral opening on the surface of the penis when the newborn voids.
- B. Perform transillumination of the scrotal sac to visualize shadows of the testes.
- C. Use a fingertip to palpate the inguinal canal for a retractile or undescended testis.
- D. Measure the size of the scrotal sac for length and width.
Correct Answer: C
Rationale: If the testes are not palpated in the scrotum, the next step is to check the inguinal canal for a retractile or undescended testis. This technique allows the nurse to determine if the testes are located within the inguinal canal rather than the scrotum. It is essential to assess for the presence of testes in the inguinal canal to ensure proper diagnosis and management of any potential issues related to testicular positioning.
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The nurse instructs a laboring client to use accelerated-blow breathing. The client begins to complain of tingling fingers and dizziness. What action should the nurse take?
- A. Administer oxygen by face mask.
- B. Notify the healthcare provider of the client's symptoms.
- C. Have the client breathe into her cupped hands.
- D. Check the client's blood pressure and fetal heart rate.
Correct Answer: C
Rationale: Tingling fingers and dizziness are symptoms of hyperventilation, which can occur with accelerated-blow breathing. Instructing the client to breathe into her cupped hands can help rebreathe exhaled carbon dioxide, which can alleviate the symptoms by restoring the proper balance of oxygen and carbon dioxide in the blood. This intervention can be effective in managing the client's hyperventilation without the need for additional medical interventions at this point.
During the admission procedure of a 6-year-old, the child states, 'I'm going to have an operation.' Which response is best for the nurse to provide to this child?
- A. Are you scared?
- B. We're going to do everything we can to take very good care of you.
- C. Tell me what an operation is.
- D. I'm glad your mother told you why you were coming to the hospital.
Correct Answer: B
Rationale: In this situation, the most appropriate response for the nurse is to provide reassurance and express care to alleviate the child's anxiety about the upcoming operation. By reassuring the child that everything will be done to take very good care of them, the nurse helps build trust and comfort, creating a positive and supportive environment for the child.
A pregnant woman comes to the prenatal clinic for an initial visit. In reviewing her childbearing history, the client indicates that she has delivered premature twins, one full-term baby, and has had no abortions. Which GTPAL should the LPN/LVN document in this client's record?
- A. 3-1-2-0-3.
- B. 4-1-2-0-3.
- C. 2-1-2-1-2.
- D. 3-1-1-0-3.
Correct Answer: D
Rationale: The correct GTPAL for this client is 3-1-1-0-3. G (Gravida) is 3, indicating a total of 3 pregnancies. T (Term) is 1, representing 1 full-term delivery. P (Preterm) is 1, not 2 as mentioned in the question, as twins count as one pregnancy event. A (Abortions) is 0, and L (Living) is 3, indicating 3 living children (twins count as 1). Therefore, the correct answer is 3-1-1-0-3.
The nurse is caring for a 2-day old neonate who has not passed meconium and has a swollen abdomen. The healthcare provider reviews the flat plate X-ray of the abdomen and makes a tentative diagnosis of Hirschsprung's disease. Which pathophysiological process is consistent with this neonate's clinical picture?
- A. The congenital absence of parasympathetic ganglion cells to large intestine produces no peristalsis.
- B. Pyloric obstruction causes reflux and projectile hematemesis.
- C. Partial imperforated anal opening limits passage of stools.
- D. Peristalsis moving against the intestinal obstruction causing hyperactivity of the bowel.
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A male infant with a 2-day history of fever and diarrhea is brought to the clinic by his mother, who tells the nurse that the child refuses to drink anything. The nurse determines that the child has a weak cry with no tears. Which intervention is most important to implement?
- A. Provide a bottle of electrolyte solution.
- B. Infuse normal saline intravenously.
- C. Administer an antipyretic rectally.
- D. Apply an external cooling blanket.
Correct Answer: B
Rationale: Infusing normal saline intravenously is crucial to treat dehydration caused by fever and diarrhea. In this scenario, the infant's weak cry with no tears indicates severe dehydration, necessitating rapid fluid replacement via intravenous normal saline to restore fluid balance and prevent complications.