Nokea
If the nurse documents all the following data, which finding should be reported immediately?
- A. Refusal to eat
- B. Complaint of nausea
- C. Absent bowel sounds
- D. Temperature of 101°F (38.3°C) orally
Correct Answer: C
Rationale: Absent bowel sounds may indicate peritonitis or bowel obstruction, serious complications of appendicitis requiring immediate reporting to prevent further deterioration.
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The common possible cause of oligohydramnios is:
- A. Oesophageal atresia.
- B. Placental haemangioma.
- C. Renal agenesis.
- D. Diabetes mellitus.
- E. Rh incompatibility.
Correct Answer: C
Rationale: Renal agenesis leads to oligohydramnios because the fetus cannot produce urine a major component of amniotic fluid. Other options are less commonly associated with reduced amniotic fluid.
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.
Which of the following statements made by the adolescent best supports the nurse's suspicion of scoliosis?
- A. My friends are getting taller faster than I am.
- B. One of my sleeves is always shorter than the other.
- C. I have a difficult time sleeping on my side at night.
- D. I have a difficult time sleeping on my side at night.
Correct Answer: B
Rationale: Uneven sleeve length suggests shoulder asymmetry, a common sign of scoliosis due to lateral spinal curvature affecting posture.
A 30 years old G5P4 is admitted in labor room with H/O 32 weeks gestation,mild vaginal bleeding and abdominal pain. O/E her blood pressure 140/100 mm Hg abdomen is tense tender and hard. Fetal heart sounds are not audible. What is the most likely diagnosis:
- A. Placenta praevia.
- B. Abruptio placenta.
- C. Preterm labour.
- D. Urinary tract infection.
- E. Vasa praevia.
Correct Answer: B
Rationale: Abruptio placenta presents with vaginal bleeding abdominal pain a tense uterus and fetal distress (absent heart sounds) often with hypertension. Placenta previa typically causes painless bleeding and other options do not match the clinical picture.
The nurse admits the term newborn,who is at risk to develop neonatal abstinence syndrome (NAS) to the newborn nursery. The nurse correctly places this infant in which location?
- A. The general nursery with 15 other infants
- B. A small,well-lit nursery with two other newborns
- C. Alone in a small,darkened nursery room
- D. Right next to the charge nurse’s desk
Correct Answer: C
Rationale: Newborns with NAS require a low-stimulus environment due to withdrawal behaviors. A small darkened room alone minimizes noise and light stimulation.