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It is noted that a baby admitted to the nursery has translucent skin with visible veins. Because of this finding, the nurse should monitor this baby carefully for which of the following?
- A. Polycythemia.
- B. Hypothermia.
- C. Hyperglycemia.
- D. Polyuria.
Correct Answer: B
Rationale: Translucent skin with visible veins is common in preterm infants, who are at higher risk for hypothermia due to poor thermoregulation.
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A school nurse is discussing the male reproductive system with the students in a high school health class. Which of the following information about the hormone testosterone should be included in the discussion?
- A. Testosterone is what makes boys more muscular than girls.'
- B. The level of testosterone in boys changes every month like female hormones do.'
- C. Testosterone is produced by the male prostate gland.'
- D. The production of testosterone usually stops by the time a man is fifty years old.'
Correct Answer: A
Rationale: Testosterone is responsible for the development of male secondary sexual characteristics, including increased muscle mass.
Which of the following features would the nurse expect to be absent in an 8-week-gestation embryo?
- A. Four-chambered heart.
- B. Fingers and toes.
- C. Fully formed genitalia.
- D. Facial features.
Correct Answer: C
Rationale: At 8 weeks, the embryo’s genitalia are not fully formed, though other features like the heart and facial structures are developing.
When should the nurse begin discharge planning?
- A. When the patient is ready
- B. Close to the time of discharge
- C. Upon admission to the hospital
- D. After an order is written/prescribed
Correct Answer: C
Rationale: Discharge planning begins the moment a patient is admitted to a health care facility.
A nurse is teaching the staff about the Institute of Medicine competencies. Which examples indicate the staff has a correct understanding of the teaching? (Select all that apply.)
- A. Use informatics.
- B. Use transparency.
- C. Apply globalization.
- D. Apply quality improvement.
Correct Answer: D
Rationale: The Institute of Medicine competencies include: Provide patient-centered care; work in interdisciplinary teams; use evidence-based practice; apply quality improvement; and use informatics. Transparency is included in the 10 rules of performance in a redesigned health care system, not a competency. While globalization is important in health care, it is not a competency.
A woman, contracting every 3 min 60 seconds, suddenly develops an amniotic fluid embolism. Which of the following signs/symptoms would the nurse observe?
- A. Sudden gush of fluid from the vagina.
- B. Intense and unrelenting uterine pain.
- C. Precipitous dilation and expulsion of the fetus.
- D. Chest pain with dyspnea and cyanosis.
Correct Answer: D
Rationale: Amniotic fluid embolism can cause sudden cardiovascular collapse, including chest pain, dyspnea, and cyanosis.