Nokea
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.
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The nurse is assessing the full-term Caucasian infant who is 40 hours old. Which technique should the nurse use to evaluate the infant for jaundice?
- A. Remove the infant’s diaper and look at the color of the genitalia.
- B. Apply pressure on the forehead for 3 seconds,release and evaluate the skin color.
- C. Assess the color of the palms and compare that skin color to the color of the soles.
- D. Open the infant’s mouth to assess the color of the infant’s tongue and palate.
Correct Answer: B
Rationale: To differentiate jaundice from normal skin color apply pressure over a bony area like the forehead. A yellow blanched area indicates jaundice. Genitalia palms soles or oral mucosa are less reliable due to slower progression or darker pigmentation.
A G2P1 with previous cesarean section due to obstructed labour comes for first antenatal visit at 34 weeks of gestation. She is seeking advice for home delivery this time. What will be the most dangerous complication in her case if we allow her to deliver at home by untrained birth attendent:
- A. Prolonged latent phase.
- B. Arrest in second stage of labour.
- C. Delayed progress in active phase of labour.
- D. Rupture uterus.
- E. Placental retention.
Correct Answer: D
Rationale: Uterine rupture is a life-threatening complication in women with a previous cesarean section especially during labor managed by untrained attendants due to the risk of scar dehiscence. Other complications are less immediately dangerous.
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.
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.
Which diversional activity is best for meeting the burned child's developmental needs?
- A. Reading the newspaper
- B. Coloring simple designs
- C. Playing with an action figure
- D. Playing a solitary card game
Correct Answer: B
Rationale: Coloring simple designs is a developmentally appropriate activity for a school-age child, promoting fine motor skills and creativity while being feasible for a bedridden patient with burns.