Nokea
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.
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The nurse is caring for the full-term newborn male who is 24 hours old and was circumcised with a Gomco clamp 30 minutes ago. Which interventions should the nurse plan for care of the newborn’s circumcision? Select all that apply.
- A. Monitor the newborn’s penis hourly for 4 to 6 hours.
- B. Observe for and document the first voiding after circumcision.
- C. Use prepackaged commercial diaper wipes for perineal cleansing.
- D. Apply petroleum ointment around the penis after each diaper change.
- E. Apply tightly a size-smaller diaper to provide hemostasis.
Correct Answer: A,B,D
Rationale: Monitor the penis for swelling/bleeding document first void to rule out obstruction and apply petroleum ointment to prevent bleeding. Commercial wipes may irritate and tight diapers cause pain.
The nurse informs the client that acquired immunodeficiency syndrome (AIDS) is commonly associated with which symptoms?
- A. Increased appetite and chills during the night
- B. Tachycardia, dyspnea, and constipation
- C. Fatigue, fever, and persistent yeast infections
- D. Weight gain, peripheral edema, and jaundice
Correct Answer: C
Rationale: AIDS is associated with fatigue, fever, and persistent infections like yeast infections due to immune suppression, making these symptoms characteristic.
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.
If the child develops shortness of breath when ambulating to the bathroom in the hospital, which intervention should the nurse add to the care plan?
- A. Have the child use a bedside commode for elimination.
- B. Administer oxygen after the child uses the bathroom.
- C. Instruct the child to call for assistance when ambulating to the bathroom.
- D. Provide a walker for the child to use when ambulating to the bathroom.
Correct Answer: A
Rationale: Shortness of breath during ambulation may indicate carditis, a serious complication of rheumatic fever. Using a bedside commode minimizes physical exertion, reducing cardiac workload and the risk of worsening symptoms.
23 years old primigravida presents to you at fourteen weeks of gestation. She is concerned about normality of fetus. At what time you will advice her detailed fetal anomaly scan:
- A. 22-24 weeks.
- B. 14-16 weeks.
- C. 18-22 weeks.
- D. 10-14 weeks.
- E. 24-28 weeks.
Correct Answer: C
Rationale: A detailed fetal anomaly scan is typically performed between 18-22 weeks of gestation as this is the optimal time to visualize fetal anatomy clearly. Earlier scans (10-14 weeks) are for nuchal translucency and later scans may miss the window for detailed structural assessment.