Nokea
The nurse assesses that the 8-hour-old infant’s axillary temperature is 97°F (36.1°C). Which intervention should the nurse implement first?
- A. Document the findings as abnormal.
- B. Place the infant under a radiant warmer.
- C. Feed the infant formula that is warmed.
- D. Call the HCP to report the temperature.
Correct Answer: B
Rationale: An axillary temperature of 97°F is below the normal range (97.7°F–98.9°F). The infant should be gradually rewarmed under a radiant warmer. Documentation follows intervention feeding warm formula is unnecessary and HCP notification is needed only if warming fails.
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Which of the following statements made by the adolescent best supports the nurse's suspicion of scoliosis?
- A. My friends are getting taller faster than I am.
- B. One of my sleeves is always shorter than the other.
- C. I have a difficult time sleeping on my side at night.
- D. I have a difficult time sleeping on my side at night.
Correct Answer: B
Rationale: Uneven sleeve length suggests shoulder asymmetry, a common sign of scoliosis due to lateral spinal curvature affecting posture.
The nurse is reviewing the following labor history of a postpartum mother: “Mother positive for group B streptococcal (GBS) infection at 37 weeks’ gestation. Membranes ruptured at home 14 hours before presentation to the hospital at 40 weeks’ gestation. Precipitous labor,no antibiotic given.” Considering this information the nurse should observe her 15-hour-old newborn closely for which finding?
- A. Temperature instability
- B. Pink stains in the diaper
- C. Meconium stools
- D. Presence of erythema toxicum
Correct Answer: A
Rationale: GBS infection risk increases with prolonged membrane rupture and no antibiotics with temperature instability as an early symptom. Pink stains meconium and erythema toxicum are normal.
The nurse admits the term newborn,who is at risk to develop neonatal abstinence syndrome (NAS) to the newborn nursery. The nurse correctly places this infant in which location?
- A. The general nursery with 15 other infants
- B. A small,well-lit nursery with two other newborns
- C. Alone in a small,darkened nursery room
- D. Right next to the charge nurse’s desk
Correct Answer: C
Rationale: Newborns with NAS require a low-stimulus environment due to withdrawal behaviors. A small darkened room alone minimizes noise and light stimulation.
Vaginal examination is contraindicated in pregnancy in which situation:
- A. Carcinoma of cervix.
- B. Gonorrhoea.
- C. Prolapsed cord.
- D. Placenta previa.
- E. Active labour.
Correct Answer: D
Rationale: Placenta previa contraindicates vaginal examination due to the risk of provoking severe hemorrhage. Other conditions may require caution but are not absolute contraindications.
Which findings by the nurse best indicate that the child is experiencing diabetic ketoacidosis? Select all that apply.
- A. Blood glucose level of 120 mg/dL
- B. Fruity-smelling breath
- C. Pale-colored face
- D. Excessive perspiration
- E. Deep, rapid breathing
- F. Dry, flushed skin
Correct Answer: B,E,F
Rationale: Diabetic ketoacidosis (DKA) is characterized by hyperglycemia (blood glucose typically >250 mg/dL, so 120 mg/dL is incorrect), fruity-smelling breath due to acetone, deep and rapid breathing (Kussmaul respirations) to compensate for acidosis, and dry, flushed skin due to dehydration.