Nokea
The nurse caring for a 32-weeks’ gestation infant is about to perform a heel stick to obtain blood for a prescribed test. Which intervention should the nurse utilize to minimize the amount of pain the neonate will experience?
- A. Apply an ice pack
- B. Apply a heel warmer
- C. Give morphine sulfate
- D. Give sucrose or Sweet-Ease
Correct Answer: D
Rationale: Sucrose activates the endogenous opioid system providing analgesia for 3–5 minutes when given 2 minutes prior to a heel stick. Ice risks skin damage heel warmers aid blood flow and morphine is inappropriate.
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Which of the following test is used in screening for Down's syndrome:
- A. Ca 125.
- B. Carcino embryonic antigen CAE.
- C. Triple screening including β HCG,AFP,serum estriol.
- D. FSH,LH.
- E. Thyroid hormone.
Correct Answer: C
Rationale: The triple screen (β-hCG AFP serum estriol) is used in the second trimester to screen for Down syndrome. Other tests are not relevant for this purpose.
The physician orders an I.V. opioid analgesic. Which finding by the nurse would best indicate that the I.V. opioid analgesic is effective?
- A. The respiratory rate is within normal limits.
- B. The child's pain level remains stable.
- C. The child is watching television.
- D. The urine output is 30 mL/hour.
Correct Answer: C
Rationale: A child watching television suggests they are comfortable and distracted from pain, indicating effective pain relief from the opioid. Stable pain levels or normal respiratory rate do not directly confirm pain control.
The nurse evaluates that the newborn’s Moro reflex is WNL. Which response by the newborn prompted the nurse’s conclusion?
- A. Straightens extremities and then flexes them in response to a loud noise
- B. Right-side extremity extension when the head is quickly turned right
- C. Turns the head toward the right side when the right cheek is touched
- D. Attempts to walk when the sole of the foot touches a hard surface
Correct Answer: A
Rationale: An intact Moro reflex involves extremity extension then flexion in response to a loud noise. Other options describe tonic neck rooting and stepping reflexes.
The nurse correctly advises the adolescent that the brace has to be worn during which time period?
- A. At all times except when bathing
- B. At least 8 hours each day
- C. At night while sleeping
- D. At all times, without exception
Correct Answer: A
Rationale: The Milwaukee brace is typically worn 23 hours a day, except during bathing, to effectively correct scoliosis by maintaining spinal alignment.
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.