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The LPN/LVN identifies crepitus when examining the chest of a newborn who was delivered vaginally. Which further assessment should the nurse perform?
- A. Elicit a positive scarf sign on the affected side.
- B. Observe for an asymmetrical Moro (startle) reflex.
- C. Watch for swelling of fingers on the affected side.
- D. Note paralysis of the affected extremity and muscles.
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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After each feeding, a 3-day-old newborn is spitting up large amounts of Enfamil® Newborn Formula, a nonfat cow's milk formula. The pediatric healthcare provider changes the neonate's formula to Similac® Soy Isomil® Formula, a soy protein isolate-based infant formula. What information should the LPN/LVN provide to the mother about the newly prescribed formula?
- A. The new formula is a coconut milk formula used with babies with impaired fat absorption.
- B. Enfamil® Formula is a demineralized whey formula that is needed with diarrhea.
- C. The new formula is a casein protein source that is low in phenylalanine.
- D. Similac® Soy Isomil® Formula is a soy-based formula that contains sucrose.
Correct Answer: D
Rationale: The LPN/LVN should inform the mother that Similac® Soy Isomil® Formula is a soy-based formula containing sucrose. This formula is suitable for infants with cow's milk protein allergy or intolerance, which may be the reason for the newborn spitting up large amounts of the previous cow's milk formula.
What action should the nurse take if an infant, who was born yesterday weighing 7.5 lbs (3,402 grams), weighs 7 lbs (3,175 grams) today?
- A. Inform and assure the mother that this is normal weight loss.
- B. Encourage the mother to increase the frequency of breastfeeding.
- C. After verifying the accuracy of weight, notify the healthcare provider.
- D. Monitor the stool and urine output of the neonate for the last 24 hours.
Correct Answer: A
Rationale: The correct action for the nurse to take in this situation is to inform and assure the mother that this weight loss is normal. Newborns can lose up to 10% of their birth weight in the first few days after birth, which is attributed to fluid loss and adjustment to life outside the womb. This weight loss is typically regained within the first two weeks of life. It is crucial for the nurse to educate and provide reassurance to the mother about this common occurrence in newborns.
During a non-stress test (NST) at 41-weeks gestation, the LPN/LVN notes that the client is not experiencing contractions, the fetal heart rate (FHR) baseline is 144 bpm, and no FHR accelerations are present. What action should the nurse take?
- A. Check the client for urinary bladder distention.
- B. Notify the healthcare provider of the nonreactive results.
- C. Have the mother stimulate the fetus to move.
- D. Ask the client if she has felt any fetal movement.
Correct Answer: D
Rationale: In this scenario, the nurse should ask the client if she has felt any fetal movement. This action is important as assessing for fetal movement can help determine if the absence of FHR accelerations is attributed to fetal sleep or decreased fetal activity. It is crucial to gather information directly from the client to aid in the assessment and decision-making process. This approach can provide valuable insights into the fetal well-being and guide further interventions if needed.
Upon admission to the prenatal clinic, a 23-year-old woman informs the nurse that her last menstrual period began on February 15, and that previously her periods were regular. Her pregnancy test is positive. What is this client's expected date of delivery (EDD)?
- A. November 22.
- B. November 8.
- C. December 22.
- D. October 22.
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
When counseling a couple seeking information about conceiving, the LPN/LVN should know that ovulation usually occurs
- A. two weeks before menstruation.
- B. immediately after menstruation.
- C. immediately before menstruation.
- D. three weeks before menstruation.
Correct Answer: A
Rationale: Ovulation typically occurs about 14 days before the start of the next menstrual period. This timing allows for the released egg to travel down the fallopian tube where it may be fertilized by sperm, leading to conception. Understanding the timing of ovulation is crucial for couples trying to conceive to increase their chances of success.