Nokea
The mother of a 2-week-old infant tells the nurse, 'I think the baby is constipated. I've noticed she strains when she has a bowel movement.' What is nurse's most helpful response?
- A. Give the baby one serving of fruit per day.'
- B. Increase the amount and frequency of her feedings.'
- C. It sounds like the baby is uncomfortable because she is constipated.'
- D. Newborns might strain with bowel movements because their muscles aren't fully developed.'
Correct Answer: D
Rationale: Straining in the newborn period is normal. It results from underdeveloped abdominal musculature. No treatment is required.
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What action does the nurse implement to protect newborns from infection while in the nursery?
- A. Keep the newborn dressed warmly.
- B. Adjust room temperature between 23.8°C (75°F) and 26.6°C (80°F).
- C. Wash hands before touching each infant.
- D. Wear a disposable gown when giving infant care.
Correct Answer: C
Rationale: Hand washing is the most reliable precaution available to prevent infection. The nurse washes his or her hands between handling different babies.
Which of the following actions by a community health nurse is most appropriate when noting multiple bruises and burns on the posterior trunk of an 18-month-old child during a home visit?
- A. Report the child's condition to Protective Services immediately.
- B. Schedule a follow-up visit to check for more bruises.
- C. Notify the child's physician immediately.
- D. Do nothing because this is a normal finding in a toddler.
Correct Answer: A
Rationale: Multiple bruises and burns on a toddler are signs child abuse. Therefore, the nurse is responsible for reporting the case to Protective Services immediately to protect the child from further harm.
A 14-year-old boy has acne and according to his parents, dominates the bathroom by using the mirror all the time. Which of the following remarks by the nurse would be least helpful in talking to the boy and his parents?
- A. This is probably the only concern he has about his body. So don't worry about it or the time he spends on it.'
- B. Teenagers are anxious about how their peers perceive them. So they spend a lot of time grooming.'
- C. A teen may develop a poor self-image when experiencing acne. Do you feel this way sometimes?'
- D. You appear to be keeping your face well washed. Would you feel comfortable discussing your cleansing method?'
Correct Answer: A
Rationale: Stating that this is probably the only concern the adolescent has and telling the parents not to worry about it or the time he spends on it shuts off further investigation and is likely to make the adolescent and his parents feel defensive.
Which of the following assessment findings would lead the nurse to suspect Down syndrome in an infant?
- A. Small tongue
- B. Transverse palmar crease
- C. Large nose
- D. Restricted joint movement
Correct Answer: B
Rationale: Down syndrome is characterized by the following a transverse palmar crease (simian crease), separated sagittal suture, oblique palpebral fissures, small nose, depressed nasal bridge, high-arched palate, excess and lax skin, wide spacing and plantar crease between the second and big toes, hyperextensible and lax joints, large protruding tongue, and muscle weakness.
After the examination is completed, the patient asks the nurse why Chadwicks sign occurs during pregnancy. What would the nurse explain as the cause of Chadwicks sign?
- A. Enlargement of the uterus
- B. Progesterone action on the breasts
- C. Increasing activity of the fetus
- D. Vascular congestion in the pelvic area
Correct Answer: D
Rationale: Chadwicks sign is caused by increased vascular congestion in the cervical and vaginal area.