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In a routine prenatal visit, the nurse examining a patient who is 37 weeks pregnant notices that the fetal heart rate (FHR) has dropped to 120 beats/min from a rate of 160 beats/min earlier in the pregnancy. What is the nurses first action?
- A. Ask if the patient has taken a sedative.
- B. Notify the physician.
- C. Turn the patient to her right side.
- D. Record the rate as a normal finding.
Correct Answer: D
Rationale: The FHR at term ranges from a low of 110 to 120 beats/min to a high of 150 to 160 beats/min. This should be recorded as normal. The FHR drops in the late stages of pregnancy.
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What is the total number of chromosomes contained in a mature sperm or ovum?
- A. 22
- B. 23
- C. 44
- D. 46
Correct Answer: B
Rationale: Gametes (sex chromosomes) contain 23 chromosomes.
A hospitalized schoolager states: 'I'm not afraid of this place, I'm not afraid of anything.' This statement is most likely an example of which of the following?
- A. Regression
- B. Repression
- C. Reaction formation
- D. Rationalization
Correct Answer: C
Rationale: Reaction formation is the schoolager's typical defensive response when hospitalized. In reaction formation, expression of unacceptable thoughts or behaviors is prevented (or overridden) by the exaggerated expression of opposite thoughts or types of behaviors.
You’re assessing the one minute APGAR score of a newborn baby. On assessment, you note the following about your newborn patient: heart rate 101, cyanotic body and extremities, no response to stimulation, no flexion of extremities, and strong cry. What is your patient’s APGAR score?
- A. APGAR 4
- B. APGAR 6
- C. APGAR 3
- D. APGAR 2
Correct Answer: A
Rationale: APGAR scoring: Heart rate 101 (2 points), cyanotic body/extremities (0 points), no response to stimulation (0 points), no flexion (0 points), strong cry (2 points). Total = 2 + 0 + 0 + 0 + 2 = 4.
When assessing a child with a cleft palate, the nurse is aware that the child is at risk for more frequent episodes of otitis media due to which of the following?
- A. Lowered resistance from malnutrition
- B. Ineffective functioning of the Eustachian tubes
- C. Plugging of the Eustachian tubes with food particles
- D. Associated congenital defects of the middle ear.
Correct Answer: B
Rationale: Because of the structural defect, children with cleft palate may have ineffective functioning of their Eustachian tubes creating frequent bouts of otitis media.
Which statement indicates the parents understand when to contact the pediatrician or nurse practitioner?
- A. Infant refuses a feeding
- B. Infant has an axillary temperature of 97°F
- C. Infant has three pasty, yellow-brown stools in 24 hours
- D. Infant's diaper is not wet after 8 hours
Correct Answer: D
Rationale: Decreased or lack of voiding by the newborn should be reported to the pediatrician or nurse practitioner to prevent dehydration.