Nokea
The first-time mother of the 2-hour-old full-term newborn worriedly tells the nurse,“Something black is coming out of my baby.” After determining that the newborn has passed stool which statement by the nurse is most appropriate?
- A. “Black stools could be from bleeding. I will notify your provider now.”
- B. “Breastfeeding will cause all the baby’s stools to be this dark in color.”
- C. “Babies normally pass this type of stool initially; it is called meconium.”
- D. “I’ll check the baby’s temperature; this occurs when babies need warming.”
Correct Answer: C
Rationale: Meconium a greenish-black stool is normal within 24 hours after birth formed from amniotic fluid and intestinal secretions. It’s not related to bleeding breastfeeding or temperature.
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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.
Which intervention is best to prevent complications associated with traction and immobility?
- A. Offer the child fluids on a frequent basis.
- B. Assist the child to select low-fiber foods.
- C. Assist the child to select low-fiber foods daily.
- D. Reposition the child onto the side every 2 hours.
Correct Answer: A
Rationale: Frequent fluid intake prevents urinary stasis and constipation, common complications of immobility in traction, supporting hydration and kidney function.
The client with oligohydramnios and possible intrauterine growth restriction gives birth. The newborn’s 1-minute Apgar score was 6,and the 5-minute Apgar score is 7. Which conclusion should the nurse make from this information?
- A. A low Apgar score at 1 minute correlates with infant mortality.
- B. The 5-minute Apgar score of 7 is within normal parameters.
- C. Neurological problems are unlikely with a 5-minute score of 7.
- D. Oligohydramnios would not have affected the Apgar score.
Correct Answer: B
Rationale: A 5-minute Apgar score at or above 7 is considered normal. A low 1-minute score is not associated with mortality but a low 5-minute score is. Apgar scores are poor predictors of neurological outcomes and oligohydramnios can affect scores.
Of the following methods,the safest,most precise and simplest for placental localization is:
- A. Auscultation.
- B. Ultrasonography.
- C. Radioisotope study.
- D. Abdominal palpation.
- E. Soft tissue radiography.
Correct Answer: B
Rationale: Ultrasonography is the safest most precise and simplest method for placental localization offering real-time imaging without radiation. Other methods are less accurate or involve risks.
If the client asks the nurse for instructions on safe condom use, which information needs to be stressed?
- A. Condoms should be stored in a warm, dry place to prevent damage.
- B. Condoms are generally lubricated with mineral oil or petroleum jelly.
- C. A condom should be applied before the penis becomes erect.
- D. During application, a ½†space should be left at the end of the condom.
Correct Answer: D
Rationale: Leaving a ½†space at the condom's tip prevents breakage by allowing room for semen, a critical aspect of safe condom use to ensure effectiveness.