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Student practical nurses are discussing the North American Nursing Diagnosis Association International (NANDA-I) taxonomy in post conference on the acute care clinical setting. The students are aware that the role of the LPN with nursing diagnosis formulation is what?
- A. To initiate and identify nursing diagnosis specific to patient
- B. To update changes in nursing diagnosis as needed
- C. To have an understanding of nursing diagnosis terminology
- D. To accurately document nursing diagnosis on patient plan of care
Correct Answer: C
Rationale: The registered nurse is responsible to initiate, identify, update, and document nursing diagnoses. The licensed practical nurse is responsible to have an understanding of nursing diagnosis terminology.
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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.
When the newborn's crib was moved suddenly, the nurse noticed that his legs flexed and arms fanned out, and then both came back toward the midline. How would the nurse interpret this behavior?
- A. The more review
- B. The grasp reflex
- C. An abnormality of the musculoskeletal system
- D. A neurological abnormality
Correct Answer: A
Rationale: The Moro reflex is a normal neonatal reflex. It is elicited when the infant's crib is jarred. The infant responds by drawing the legs up, fanning the arms, and then bringing the arms to the midline in an embrace position.
You are the clinician on duty at Rabuor health centre when a mother is brought by relatives having delivered at home 2 days ago. When you examine the baby you find a tiny infant weighing $1800 \mathrm{~g}$. The baby is cold with bluish lips and a weak cry. List 4 signs of prematurity. What is one sign?
- A. Low birth weight (<2500 g)
- B. High birth weight (>4000 g)
- C. Thick skin with vernix
- D. Strong sucking reflex
Correct Answer: A
Rationale: Low birth weight (<2500 g) is a hallmark sign of prematurity, consistent with this baby’s 1800 g weight.
An urban area has been reported to have a high perinatal mortality rate. What information does this provide?
- A. Maternal and infant deaths per 100,000 live births per year
- B. Deaths of fetuses weighing more than $500 \mathrm{~g}$ per 10,000 births per year
- C. Deaths of infants up to 1 year of age per 1000 live births per year
- D. Fetal and neonatal deaths per 1000 live births per year
Correct Answer: D
Rationale: The perinatal mortality rate includes fetal and neonatal deaths per 1000 live births per year.
The nurse is aware that the diagonal conjugate is 12 centimeters. What is the measurement in centimeters of the obstetric conjugate?
- A. 10 to 10.5
- B. 11 to 11.5
- C. 12.5 to 13
- D. 14 to 14.5
Correct Answer: A
Rationale: The obstetric conjugate is approximately 1.5 to 2 centimeters shorter than the diagonal conjugate.