Nokea
Initial assessment of a term female neonate about 4 hours old reveals a normal anterior fontanel. The nurse documents its shape as which of the following?
- A. Oval.
- B. Square.
- C. Diamond shaped.
- D. Triangular.
Correct Answer: C
Rationale: The anterior fontanel in a term neonate is typically diamond-shaped.
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A client asks about the risks of long-term oral contraceptive use. Which of the following would the nurse include?
- A. Increased risk of blood clots.
- B. Permanent weight loss.
- C. Elimination of ovarian cancer risk.
- D. Guaranteed regular menstrual cycles.
Correct Answer: A
Rationale: Long-term use of oral contraceptives may increase the risk of blood clots, especially in at-risk populations. It may reduce ovarian cancer risk, does not cause permanent weight loss, and does not guarantee regular cycles.
A viable female neonate was delivered 10 minutes ago and is in stable condition under a radiant warmer. To prevent infant heat loss by convection, the nurse should:
- A. Move the infant away from cool window surfaces.
- B. Dry the infant quickly after delivery.
- C. Keep the infant away from air conditioning vents.
- D. Place the infant on a warmed surface.
Correct Answer: C
Rationale: Keeping the infant away from air conditioning vents prevents heat loss by convection, which occurs due to air movement.
A 30-year-old multigravid client at 8 weeks' gestation has a history of insulin-dependent diabetes since age 20. When explaining about the importance of blood glucose control during pregnancy, the nurse should tell the client that which of the following will occur regarding the client's insulin needs during the first trimester?
- A. They will increase.
- B. They will decrease.
- C. They will remain constant.
- D. They will be unpredictable.
Correct Answer: B
Rationale: Insulin needs typically decrease in the first trimester due to increased insulin sensitivity.
Which of the following actions should the nurse take when performing external cardiac massage on a neonate born at 28 weeks' gestation?
- A. Alternate cardiac massage with ventilation.
- B. Compress the sternum with the palm of the hand.
- C. Compress the chest 70 to 80 times per minute.
- D. Displace the chest 70 to 80 times per minute.
Correct Answer: A
Rationale: Alternating cardiac massage with ventilation follows neonatal resuscitation guidelines to restore circulation and oxygenation.
A 39-year-old multigravid client at 39 weeks' gestation admitted to the hospital in active labor has been diagnosed with class II heart disease. To ensure cardiac emptying and adequate oxygenation during labor, the nurse plans to encourage the client to do which of the following?
- A. Breathe slowly after each contraction.
- B. Avoid the use of analgesics for the labor pain.
- C. Remain in a side-lying position with the head elevated.
- D. Request local anesthesia for vaginal delivery.
Correct Answer: C
Rationale: For class II heart disease, a side-lying position with head elevation reduces cardiac strain by optimizing venous return and oxygenation. Slow breathing is helpful but less specific, avoiding analgesics may increase stress, and local anesthesia is unrelated to cardiac emptying.