Nokea
A nurse is assessing a newborn 12 hr after birth. Which of the following manifestations should the nurse report to the provider?
- A. Acrocyanosis
- B. Transient strabismus
- C. Jaundice
- D. Caput succedaneum
Correct Answer: C
Rationale: The correct answer is C: Jaundice. Jaundice in a newborn 12 hours after birth could indicate physiological jaundice, but it should still be reported to the provider for further evaluation. Jaundice can be a sign of hyperbilirubinemia, which if left untreated, can lead to complications like kernicterus. Acrocyanosis (A), transient strabismus (B), and caput succedaneum (D) are common and expected findings in newborns and do not typically require immediate reporting unless they are severe or persistent.
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The nurse conducting a physical assessment notes that a 1-day-old newborn with dark skin has a bluish-gray discoloration over the lower back, the buttocks, and the scrotum. How should this assessment finding be documented?
- A. Extensive bruising
- B. Mongolian spots
- C. Nevus flammeus
- D. Acrocyanosis
Correct Answer: B
Rationale: The correct answer is B: Mongolian spots. This finding is common in newborns with dark skin and appears as bluish-gray discoloration in areas like the lower back, buttocks, and scrotum. Mongolian spots are benign and typically fade over time. Extensive bruising (A) would present differently and usually indicates trauma. Nevus flammeus (C) refers to a port-wine stain, which is a different type of birthmark. Acrocyanosis (D) is a condition characterized by bluish discoloration of the extremities due to poor circulation, not related to the described finding.
A nurse is preparing to admit a 15-year-old client with HIV/AIDS. Based on the client's diagnosis, which of the following nursing actions is appropriate?
- A. Contribute to planning client education on standard precautions in age-appropriate manner.
- B. Contact the dietary department to request foods be delivered on disposable dishes.
- C. Prepare for infection control in a negative pressure room for this client.
- D. Instruct visitors to wear gowns and masks when entering the client's room.
Correct Answer: A
Rationale: Correct Answer: A
Rationale:
1. Client education on standard precautions is crucial to prevent the spread of infections.
2. The nurse should tailor the education in an age-appropriate manner to ensure understanding.
3. Contributing to planning education empowers the client to take an active role in their health.
4. This action promotes client safety and reduces the risk of transmission to others.
Summary:
B: Contacting the dietary department for disposable dishes is not directly related to HIV/AIDS education or infection control.
C: Preparing a negative pressure room is not necessary for standard precautions and may not be feasible in all settings.
D: Instructing visitors to wear gowns and masks is excessive for standard precautions and may cause distress to the client.
A nurse is reinforcing teaching given to the parent of a 1-year-old child who has had a high temperature, vomiting, and diarrhea for 48 hr. The child has sunken eyes and cracked lips. Which of the following should the nurse tell the parent?
- A. Give the infant applesauce and rice cereal because these have been found to have high nutritional value.
- B. Encourage the child to take sips of chicken or beef broth because they will replace the fluid losses your child is experiencing.
- C. Give the infant oral rehydration solutions that are available commercially. They replace some of the electrolytes lost through vomiting.
- D. Give the child nothing by mouth for 4 hr. Once the vomiting has decreased you can introduce sips of clear water.
Correct Answer: C
Rationale: Oral rehydration solutions effectively replace fluids and electrolytes lost due to vomiting and diarrhea.
A woman in the first trimester comes to the clinic with vaginal bleeding. The physician determines that the fetus has died and that the placenta, fetus, and tissues still remain in the uterus. How should the findings be documented?
- A. Complete abortion
- B. Stillborn abortion
- C. Missed abortion
- D. Incomplete abortion
Correct Answer: C
Rationale: The correct answer is C: Missed abortion. In a missed abortion, the fetus has died but has not been expelled from the uterus yet. The findings should be documented as a missed abortion because the fetus has not been passed naturally. This is different from a complete abortion (A) where all products of conception have been expelled, a stillborn abortion (B) which is not a recognized medical term, and an incomplete abortion (D) where some products of conception remain in the uterus. Therefore, based on the scenario described, the most appropriate term to document the findings is missed abortion.
Two days after delivery, a postpartum client prepares for discharge. What should the nurse teach her about lochia flow?
- A. Lochia does change color but goes from lochia rubra (bright red) on days 1-3, to lochia serosa (pinkish brown) on days 4-9, to lochia alba (creamy white) days 10-21.
- B. Numerous clots are abnormal and should be reported to the physician.
- C. Saturation of the perineal pad is considered abnormal and may indicate postpartum hemorrhage.
- D. Lochia normally lasts for about 21 days, and changes from a bright red, to pinkishbrown, to creamy white.
Correct Answer: D
Rationale: The correct answer is D. Lochia normally lasts for about 21 days, and changes from bright red to pinkish-brown to creamy white. This is accurate because the process of lochia flow typically follows this pattern as the uterus sheds its lining post-delivery. Lochia rubra occurs in the first few days due to blood, then transitions to serosa and alba as the bleeding decreases. Choice A is incorrect as it presents the correct information but in a confusing manner. Choices B and C are incorrect because they focus on abnormal findings rather than the normal progression of lochia.