Nokea
The agitated father of the 12-hour-old newborn reports to the nurse that his baby’s hands and feet are blue. The nurse confirms acrocyanosis and intervenes by taking which action?
- A. Immediately stimulates the infant to cry
- B. Explain that this is normal in a newborn
- C. Assess the newborn’s temperature
- D. Assess the newborn’s cardiac status
Correct Answer: B
Rationale: Acrocyanosis blueness of hands and feet is a normal newborn phenomenon in the first 24 to 48 hours after birth. The nurse should explain this to relieve anxiety. Stimulation temperature or cardiac assessments are unnecessary.
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When discussing cerebral palsy with the parents of a newly diagnosed child, which information is correct?
- A. Cerebral palsy is a nonprogressive disease caused by damage to the brain.
- B. Brain surgery commonly helps or even cures children with cerebral palsy.
- C. Physical therapy is of little value to a child with cerebral palsy.
- D. Cerebral palsy is the result of injury to the sensory areas of the brain.
Correct Answer: A
Rationale: Cerebral palsy is a nonprogressive neurological disorder caused by brain damage, often before or during birth, affecting motor function but not worsening over time.
Which suggestion by the nurse would be most helpful in relieving the teenager's menstrual pain and discomfort?
- A. Stay in bed until cramping is relieved, increase your fluid intake, and eat a low-fat diet.
- B. Drink plenty of cold liquids, add extra salt to your diet, and take a nap in the afternoon.
- C. Apply ice packs to the abdomen, eat a high-calorie diet, and have your largest meal at noon.
- D. Get at least 8 hours of sleep, eat a well-balanced diet, and apply heat to your abdomen.
Correct Answer: D
Rationale: Applying heat to the abdomen relaxes uterine muscles, reducing cramping, while adequate sleep and a balanced diet support overall health, alleviating dysmenorrhea symptoms.
Thyrotoxicosis is pregnancy is treated with:
- A. Partial thyroidectomy in first trimester.
- B. Radioiodine ablation of thyroid gland.
- C. With neomercazole.
- D. Surgery on thyroid gland in 3rd trimester.
- E. With iodine drops and β-blockers.
Correct Answer: C
Rationale: Neomercazole (carbimazole) is used to treat thyrotoxicosis in pregnancy as it controls thyroid hormone production safely. Radioiodine is contraindicated and surgery is avoided unless absolutely necessary.
The nurse is preparing the parents of a full-term,24-hour-old male newborn for discharge with their infant. Which are the expected discharge criteria that should be met before the infant leaves the hospital? Select all that apply.
- A. Infant vital signs have been normal for the last 12 hours.
- B. The infant has passed at least three meconium stools.
- C. The infant has gained weight at the minimum 100 grams.
- D. The circumcision has had no bleeding for the last 2 hours.
- E. The infant has had six diaper changes in the last 24 hours.
- F. The infant has completed 2 successful consecutive feedings.
Correct Answer: A,D,F
Rationale: Discharge criteria include stable vital signs for 12 hours no circumcision bleeding for 2 hours and two successful feedings. One meconium stool is sufficient weight gain isn’t required and diaper changes aren’t specified.
Which clinical manifestation of the client's full-thickness burns would the nurse detect during an assessment?
- A. Moderate level of pain due to exposed nerve endings
- B. Eschar formation throughout the area of the burn
- C. The appearance of blister formation throughout the area of the burn
- D. Noted tissue destruction extending to the subcutaneous layer
Correct Answer: D
Rationale: Full-thickness burns involve destruction of all skin layers, including the subcutaneous layer, resulting in a leathery or charred appearance. Pain is minimal due to nerve destruction, and blisters are characteristic of partial-thickness burns.