Nokea
Six hours after birth, the infant is found to have an area of swelling over the right parietal area that does not cross the suture line. The nurse should chart this finding as:
- A. A cephalhematoma
- B. Molding
- C. Subdural hematoma
- D. Caput succedaneum
Correct Answer: A
Rationale: A cephalhematoma is a subperiosteal hemorrhage that does not cross suture lines, commonly seen in newborns.
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A 25-year-old male is brought to the emergency room with a piece of metal in his eye. The first action the nurse should take is:
- A. Use a magnet to remove the object.
- B. Rinse the eye thoroughly with saline.
- C. Cover both eyes with paper cups.
- D. Patch the affected eye.
Correct Answer: C
Rationale: Covering both eyes prevents eye movement, reducing further damage.
The mother of a male child with cystic fibrosis tells the nurse that she hopes her son's children won't have the disease. The nurse is aware that:
- A. There is a 25% chance that his children will have cystic fibrosis.
- B. Most of the males with cystic fibrosis are sterile.
- C. There is a 50% chance that his children will be carriers.
- D. Most males with cystic fibrosis are capable of having children, so genetic counseling is advised.
Correct Answer: B
Rationale: Most males with cystic fibrosis are sterile due to congenital absence of the vas deferens, significantly reducing the likelihood of having biological children.
A client admitted for treatment of a deep venous thrombosis of the calf complains of dyspnea and chest pain. What is the best response by the nurse?
- A. administer oxygen at 2 L/min as ordered prn
- B. place client in a semi-Fowler's position
- C. prepare client for diagnostic tests
- D. obtain vital signs
Correct Answer: C
Rationale: Dyspnea and chest pain suggest a possible pulmonary embolism, a complication of DVT, requiring immediate preparation for diagnostic tests to confirm and treat.
Assuming that all have achieved normal cognitive and emotional development, which of the following children is at greatest risk for accidental poisoning?
- A. A 6-month-old
- B. A 4-year-old
- C. A 12-year-old
- D. A 13-year-old
Correct Answer: B
Rationale: A 4-year-old is at greatest risk due to their curiosity, mobility, and tendency to explore their environment, often putting objects in their mouths.
A 4-year-old is scheduled for a routine tonsillectomy. Which of the following lab findings should be reported to the doctor?
- A. A hemoglobin of 12 Gm
- B. A platelet count of 200,000
- C. A white blood cell count of 16,000
- D. A urine specific gravity of 1.010
Correct Answer: C
Rationale: A white blood cell count of 16,000 suggests infection or inflammation, which should be reported before surgery.