Nokea
The nurse conducting a physical assessment notes that a 1-day-old newborn with dark skin has a bluish-gray discoloration over the lower back, the buttocks, and the scrotum. How should this assessment finding be documented?
- A. Extensive bruising
- B. Mongolian spots
- C. Nevus flammeus
- D. Acrocyanosis
Correct Answer: B
Rationale: The correct answer is B: Mongolian spots. This finding is common in newborns with dark skin and appears as bluish-gray discoloration in areas like the lower back, buttocks, and scrotum. Mongolian spots are benign and typically fade over time. Extensive bruising (A) would present differently and usually indicates trauma. Nevus flammeus (C) refers to a port-wine stain, which is a different type of birthmark. Acrocyanosis (D) is a condition characterized by bluish discoloration of the extremities due to poor circulation, not related to the described finding.
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Which information is most important for the nurse to gather when a client is admitted to the unit in labor?
- A. Name of the support person
- B. Medical problems or complications
- C. Fluid preferences
- D. Amount of weight gained during the pregnancy
Correct Answer: B
Rationale: The correct answer is B: Medical problems or complications. This information is crucial for assessing the client's risk status and determining appropriate care during labor. Knowing the medical history helps identify potential complications that may arise and allows the nurse to plan for necessary interventions. Gathering information on the support person (choice A) is important but not as critical as the client's medical history. Fluid preferences (choice C) and weight gained during pregnancy (choice D) are relevant but do not directly impact the immediate care needed during labor. Without additional choices provided, it is evident that medical problems or complications (choice B) takes precedence in ensuring the safety and well-being of both the client and the baby.
The nursery nurse delays the first bottle feeding of a newborn. Which is the most common reason for the nurse's actions? The infant has:
- A. a blood glucose of 45 gm/dL
- B. a respiratory rate above 60
- C. blue hands and feet
- D. a heart murmur
Correct Answer: B
Rationale: The correct answer is B: a respiratory rate above 60. The nurse delays feeding because a high respiratory rate may indicate respiratory distress, making feeding unsafe. Feeding can lead to aspiration in infants with respiratory issues. A blood glucose of 45 gm/dL (choice A) is low but not typically a reason to delay feeding. Blue hands and feet (choice C) may indicate poor circulation, but it's not a common reason to delay feeding. A heart murmur (choice D) doesn't directly impact feeding safety.
Which data support a diagnosis of abruptio placenta in a pregnant woman?
- A. Uterine rigidity and abdominal pain
- B. Painless bleeding with soft abdomen
- C. Premature rupture of membranes and uterine contractions
- D. Bright red blood loss and elevated blood pressure
Correct Answer: A
Rationale: The correct answer is A: Uterine rigidity and abdominal pain. Abruptio placenta is characterized by premature separation of the placenta from the uterine wall. Uterine rigidity indicates the presence of a hypertonic uterus due to the sudden hemorrhage, leading to severe abdominal pain. This is a classic presentation of abruptio placenta. Choices B, C, and D do not align with the typical clinical features of abruptio placenta. Painless bleeding with a soft abdomen does not suggest an acute and painful condition like abruptio placenta. Premature rupture of membranes and uterine contractions are more indicative of preterm labor or premature rupture of membranes, not abruptio placenta. Bright red blood loss and elevated blood pressure are more characteristic of placenta previa or preeclampsia, respectively, not abruptio placenta.
A nurse is caring for a child who has hemophilia. The nurse should expect abnormal results in which of the following diagnostic tests?
- A. Fibrinogen
- B. Hemoglobin level
- C. Prothrombin time (PT)
- D. Partial thromboplastin time (PTT)
Correct Answer: D
Rationale: The correct answer is D: Partial thromboplastin time (PTT). In hemophilia, there is a deficiency in specific clotting factors, leading to prolonged PTT due to impaired intrinsic pathway function. A: Fibrinogen level is normal in hemophilia as it is not affected by clotting factor deficiencies. B: Hemoglobin level is unrelated to hemophilia and reflects oxygen-carrying capacity of blood. C: Prothrombin time (PT) evaluates the extrinsic pathway, which is typically normal in hemophilia. Therefore, the abnormal result is in PTT, making it the correct choice.
Which explanation is most appropriate when describing physiological jaundice to the parents of a newborn?
- A. The baby has a minor incompatibility of the blood.
- B. The baby is breaking down the extra red blood cells that were present at birth.
- C. The baby is getting too much breast milk, but this is not dangerous.
- D. The baby may have gotten exposed to hepatitis B during the delivery.
Correct Answer: B
Rationale: The correct answer is B: The baby is breaking down the extra red blood cells that were present at birth. Physiological jaundice in newborns occurs due to the breakdown of excess red blood cells, leading to an increase in bilirubin levels. This is a normal process as the baby's liver is still maturing.
Choice A is incorrect because minor blood incompatibility usually leads to a condition known as hemolytic disease of the newborn, not physiological jaundice. Choice C is incorrect as breast milk does not cause physiological jaundice. Choice D is incorrect because hepatitis B exposure does not directly cause physiological jaundice in newborns.