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The newborn nursery nurse is performing an admission assessment on a newborn with the diagnosis of subdural hematoma. Which intervention should the nurse implement to assess for the primary symptom associated with subdural hematoma?
- A. Monitor the urine for blood.
- B. Monitor the urinary output pattern.
- C. Test for contractures of the extremities.
- D. Test for equality of extremity reflexes.
Correct Answer: D
Rationale: A subdural hematoma can cause pressure on a specific area of the cerebral tissue. This can cause changes in the stimuli responses in the extremities on the opposite side of the body, especially if the newborn is actively bleeding. Options 1 and 2 are incorrect. After delivery, a newborn would normally be incontinent of urine. Blood in the urine would indicate abdominal trauma and would not be a result of the hematoma. Option 3 is incorrect because contractures would not occur this soon after delivery.
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As part of cardiac assessment, to palpate the apical pulse, the nurse places the fingertips at which location?
- A. At the left midclavicular line at the fifth intercostal space
- B. At the left midclavicular line at the third intercostal space
- C. To the right of the left midclavicular line at the fifth intercostal space
- D. To the right of the left midclavicular line at the third intercostal space
Correct Answer: A
Rationale: The point of maximal impulse (PMI), where the apical pulse is palpated, is normally located in the fourth or fifth intercostal space, at the left midclavicular line. Options 2, 3, and 4 are not descriptions of the location for palpation of the apical pulse.
The nurse performing a prenatal assessment on a client in the first trimester of pregnancy discovers that the client frequently consumes beverages containing alcohol. Why should the nurse initiate interventions immediately to assist the client in avoiding alcohol consumption?
- A. To reduce the potential for fetal growth restriction in utero
- B. To promote the normal psychosocial adaptation of the mother to pregnancy
- C. To minimize the potential for placental abruptions during the intrapartum period
- D. To reduce the risk of teratogenic effects to embryo's developing fetal organs and tissue
Correct Answer: D
Rationale: Alcohol consumption during the first trimester poses a significant risk for teratogenic effects, as this is a critical period for organogenesis in the developing embryo. Exposure to alcohol can lead to fetal alcohol syndrome or other congenital anomalies, making immediate intervention essential to protect fetal development. While fetal growth restriction, psychosocial adaptation, and placental abruption are concerns, they are less directly associated with early pregnancy alcohol exposure compared to teratogenic effects.
The nurse caring for a client diagnosed with a neurological disorder is planning care to maintain nutritional status. The nurse is concerned about the client's swallowing ability. Which food item should the nurse eliminate from this client's diet?
- A. Spinach
- B. Custard
- C. Scrambled eggs
- D. Mashed potatoes
Correct Answer: A
Rationale: Raw vegetables; chunky vegetables such as diced beets; and stringy vegetables such as spinach, corn, and peas are foods commonly excluded from the diet of a client with a poor swallowing reflex. In general, flavorful, warm, or well-chilled foods with texture stimulate the swallowing reflex. Soft and semisoft foods such as custards or puddings, egg dishes, and potatoes are usually effective.
The nurse assesses a peripheral intravenous (IV) dressing and notes that it is damp and the tape is loose. What action should the nurse take initially?
- A. Stop the infusion immediately.
- B. Apply a sterile, occlusive dressing.
- C. Ensure all IV tubing connections are tight.
- D. Gather the supplies needed to insert a new IV.
Correct Answer: C
Rationale: To determine subsequent nursing interventions, the nurse checks all connections to ensure tight seals while the IV infuses to help locate the source of the leak. If the leak is at the insertion site, the nurse stops the infusion, removes the IV, and inserts a new IV catheter. The nurse applies a new sterile occlusive dressing after resolving the source of the leak.
The nurse is caring for a 33-week pregnant client who has experienced a premature rupture of the membranes (PROM). Which interventions should the nurse expect to be part of the plan of care? Select all that apply.
- A. Perform frequent biophysical profiles.
- B. Monitor for elevated serum creatinine.
- C. Monitor for manifestations of infection.
- D. Teach the client how to count fetal movements.
- E. Use strict sterile technique for vaginal examinations.
- F. Inform the client about the need for tocolytic therapy.
Correct Answer: A,C,D,E
Rationale: Premature rupture of membranes (PROM) increases the risk of infection, preterm labor, and fetal compromise. Frequent biophysical profiles assess fetal well-being. Monitoring for manifestations of infection is critical due to the risk of chorioamnionitis. Teaching the client to count fetal movements helps monitor fetal activity and detect potential distress. Strict sterile technique for vaginal examinations minimizes infection risk. Monitoring serum creatinine is not directly related to PROM management. Tocolytic therapy may be considered but is not universally required unless preterm labor is confirmed.