Nokea
The nurse is assessing the newborn's respirations. Which of these findings would indicate a need for follow-up and further intervention?
- A. irregular respirations
- B. abdominal respirations
- C. shallow respirations
- D. 70 breaths per minute
Correct Answer: D
Rationale: The ideal respiratory rate in a newborn is 30-60 breaths per minute. A respiratory rate of 70 breaths per minute indicates tachypnea and may require intervention. Therefore, a rate of 70 breaths per minute would necessitate follow-up and further intervention. Irregular, abdominal, and shallow respirations are common in newborns and may not necessarily indicate the need for immediate follow-up or intervention.
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With a breech presentation, the nurse must be particularly alert for which of the following?
- A. quickening
- B. ophthalmia neonatorum
- C. pica
- D. prolapsed umbilical cord
Correct Answer: D
Rationale: With a breech presentation, the nurse must be particularly alert for a prolapsed umbilical cord. Prolapsed umbilical cord is a critical emergency situation where the umbilical cord descends into the vagina before the fetal presenting part, leading to compression between the presenting part and the maternal pelvis. This compression can compromise or completely cut off fetoplacental perfusion, endangering the fetus. Immediate delivery should be attempted to save the fetus. Quickening refers to fetal movements felt by the mother, ophthalmia neonatorum is an eye infection in newborns, and pica is a condition characterized by cravings for non-nutritive substances, none of which are directly related to the risks associated with a breech presentation and prolapsed umbilical cord.
Which of the following can certain foods like broccoli, oranges, dark greens, and dark yellow vegetables help improve?
- A. Vitamin intake
- B. Body functions
- C. Defense mechanisms
- D. Disease cure
Correct Answer: C
Rationale: Certain foods like broccoli, oranges, dark greens, and dark yellow vegetables can help improve defense mechanisms by enhancing the immune system and overall health. While these foods can boost defense mechanisms, they are not a cure for diseases, do not balance body functions, and are not intended to solely supplement vitamin intake, which may be necessary in some cases. Therefore, the correct answer is defense mechanisms as these foods strengthen the body's ability to fight off illnesses and maintain health.
A physician orders a serum creatinine for a hospitalized client. The nurse should explain to the client and his family that this test:
- A. is normal if the level is 4.0 to 5.5 mg/dl.
- B. can be elevated with increased protein intake.
- C. is a better indicator of renal function than the BUN.
- D. reflects the fluid volume status of a person
Correct Answer: C
Rationale: A serum creatinine level should be 0.7 to 1.5 mg/dl, and it does not vary with increased protein intake, so it is a better indicator of renal function than the BUN. Choice A is incorrect as a serum creatinine level of 4.0 to 5.5 mg/dl is not normal. Choice B is incorrect as serum creatinine is not affected by increased protein intake. Choice D is incorrect as serum creatinine primarily reflects renal function, not fluid volume status.
Which of the following microorganisms is easily transmitted from client to client on the hands of healthcare workers?
- A. mycobacterium tuberculosis
- B. clostridium tetani
- C. staphylococcus aureus
- D. human immunodeficiency virus
Correct Answer: C
Rationale: The correct answer is staphylococcus aureus. Staphylococcus aureus microorganisms are ubiquitous and easily transmitted by healthcare workers who fail to conduct routine hand washing between clients. Staphylococcus aureus can reside on the skin and be transferred from one client to another if proper hand hygiene is not practiced. Mycobacterium tuberculosis is mainly transmitted through the airborne route, clostridium tetani is usually acquired through exposure to soil or dirt contaminated with tetanus spores, and human immunodeficiency virus is not easily transmitted through casual contact or on the hands of healthcare workers.
When teaching about preventable diseases, the importance of getting the following vaccines should be emphasized:
- A. human papillomavirus, genital herpes, measles.
- B. pneumonia, HIV, mumps.
- C. syphilis, gonorrhea, pneumonia.
- D. polio, pertussis, measles
Correct Answer: D
Rationale: Vaccines are crucial in preventing communicable diseases. Smallpox has been eradicated globally, so its vaccine is no longer used. Polio, pertussis, and measles are diseases that are controlled by routine childhood immunization. While smallpox has been eradicated, these diseases still exist, making it essential for children to be vaccinated against them. Choices A, B, and C include diseases that are not prevented by vaccination or are not related to routine immunizations, making them incorrect choices.