Nokea
The nurse assesses that the full-term newborn’s head has molding. Considering this finding,which information should the nurse expect to see on the mother’s labor and delivery documentation?
- A. Vaginal breech birth
- B. Planned cesarean birth,no labor
- C. Was in labor for 16 hours
- D. Precipitous delivery after a 30-minute labor
Correct Answer: C
Rationale: A 16-hour labor causes molding due to prolonged pressure of the fetal head against the cervix. Breech births cesarean sections or short labors produce minimal or no molding.
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When a 10-year-old child falls from a bicycle and loses a permanent incisor tooth, which advice can the nurse provide to the parents before they take the child to see a dentist?
- A. Submerge the tooth in water in a cup.
- B. Place the tooth under the child's tongue.
- C. Wrap the tooth in a clean cloth.
- D. Clean the tooth with alcohol.
Correct Answer: C
Rationale: Wrapping the tooth in a clean cloth preserves it for potential reimplantation by keeping it clean and protected without compromising its viability.
Crowning is best defined as:
- A. When the greatest diameter of fetal head comes through vulva.
- B. When presenting part reaches the pelvic floor.
- C. When the perineum bulges in front of fetal head.
- D. When fetal head is visible at vulva.
- E. When head is delivered.
Correct Answer: C
Rationale: Crowning occurs when the perineum bulges due to the fetal head’s largest diameter stretching the vaginal opening just before delivery. Other definitions describe different stages.
Which nursing action is most appropriate at this time?
- A. Recognize that the fluid is cerebrospinal fluid (CSF) and remove the dressing, observing for the source of the leakage.
- B. Recognize that the fluid is CSF and call the chaplain because death of the child is imminent.
- C. Recognize that the fluid is CSF and notify the operating room because additional surgery will be necessary.
- D. Recognize that the fluid is CSF and reinforce the dressing until the physician can change it.
Correct Answer: D
Rationale: Clear drainage on a head dressing post-craniotomy is likely CSF, indicating a leak. Reinforcing the dressing prevents infection and maintains a sterile barrier until the physician assesses the leak.
Which nursing action is most appropriate when caring for a child experiencing a sickle cell crisis?
- A. Apply heat to the affected joints.
- B. Administer oxygen as ordered.
- C. Encourage vigorous physical activity.
- D. Provide a high-sodium diet.
Correct Answer: B
Rationale: Administering oxygen as ordered improves oxygenation, critical during a sickle cell crisis to counteract hypoxia caused by vaso-occlusion and reduced oxygen-carrying capacity.
Which statement by the parents indicates they understand the home care instructions given by the nurse?
- A. We've made arrangements for a homebound teacher.
- B. We'll use ice packs on our child's joints during episodes of inflammation.
- C. We'll serve meals that prevent excess weight gain.
- D. We'll keep our child in bed most of the time.
Correct Answer: C
Rationale: Maintaining a healthy weight reduces stress on inflamed joints in JRA. Serving meals that prevent excess weight gain shows understanding of home care instructions to support joint health.