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The nurse is aware that a healthy newborn's respirations are:
- A. Regular, abdominal, 40-50 per minute, deep
- B. Irregular, abdominal, 30-60 per minute, shallow
- C. Irregular, initiated by chest wall, 30-60 per minute, deep
- D. Regular, initiated by the chest wall, 40-60 per minute, shallow
Correct Answer: B
Rationale: A healthy newborn's respirations are typically irregular, abdominal, with a rate of 30-60 per minute, and tend to be shallow. Newborns have immature respiratory centers in their brain, leading to irregular breathing patterns compared to adults. Their breathing is usually abdominal due to their diaphragmatic breathing pattern. The normal respiratory rate for a newborn can fluctuate between 30-60 breaths per minute, with shallow breathing being characteristic of their physiology. Regular shallow breathing with occasional periods of apnea is considered normal in newborns and should not be a cause for concern.
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Which finding on a newborn assessment should the nurse recognize as suggestive of a clavicle fracture?
- A. Negative scarf sign
- B. Asymmetric Moro reflex
- C. Swelling of fingers on affected side
- D. Paralysis of affected extremity and muscles
Correct Answer: C
Rationale: A newborn with a clavicle fracture may present with swelling of the fingers on the affected side. This is due to the injury disrupting the nerves and blood vessels that supply the arm, leading to edema and swelling in the fingers. The other signs mentioned in the options are not typically associated with a clavicle fracture. A negative scarf sign relates to positioning of the arm and is not specific to a clavicle fracture. Asymmetric Moro reflex can be a normal finding in newborns and not indicative of a fracture. Paralysis of the affected extremity and muscles would be more suggestive of a nerve injury rather than a clavicle fracture.
The nurse practitioner assesses a client in the physician's office. Which assessment findings support a suspicion of systemic lupus erythematosus (SLE)?
- A. Facial erythema, profuse proteinuria, pleuritis, fever, and weight loss
- B. Pericarditis, photosensitivity, polyarthralgia, and painful mucous membrane ulcers
- C. Weight gain, hypervigilance, hypothermia, and edema of the legs
- D. Hypothermia, weight gain, lethargy, and edema of the arms
Correct Answer: B
Rationale: Systemic lupus erythematosus (SLE) is a chronic autoimmune disease that can affect various organs and tissues in the body. The assessment findings listed in option B are more indicative of SLE:
The nurse must assess a 10-month-old infant. The infant is sitting on the father's lap and appears to be afraid of the nurse and of what might happen next. Which initial action by the nurse would be most appropriate?
- A. Initiate a game of peek-a-boo.
- B. Ask father to place the infant on the examination table.
- C. Undress the infant while he is still sitting on his father's lap.
- D. Talk softly to the infant while taking him from his father.
Correct Answer: D
Rationale: Talking softly to the infant while taking him from his father would be the most appropriate initial action by the nurse in this situation. This approach allows the nurse to maintain communication with the infant to provide comfort and minimize fear or anxiety. By using a gentle tone and reassuring words, the nurse can help establish a sense of safety for the infant as he is transitioned from his father's lap to the examination table. This gradual and supportive approach is likely to facilitate a smoother assessment process and help build trust with the infant and the family.
The normal range of hemoglobin in the blood of an adult:
- A. 7-11 mg
- B. 14-20 mg
- C. 12-18 mg
- D. 20-26 mg
Correct Answer: C
Rationale: The normal range of hemoglobin in the blood of an adult is typically between 12-18 grams per deciliter (g/dL). Hemoglobin is a protein found in red blood cells that is responsible for carrying oxygen from the lungs to the tissues in the body. Having an adequate level of hemoglobin is essential for proper oxygen delivery throughout the body. Values outside of the normal range may indicate anemia (low hemoglobin levels) or other underlying health conditions. It's important to consult a healthcare provider for interpretation of specific hemoglobin test results.
The most serious manifestation of lead intoxication is
- A. peripheral neuropathy
- B. mental retardation
- C. anemia
- D. cerebral edema
Correct Answer: D
Rationale: Cerebral edema is the most serious manifestation of lead intoxication, as it can be life-threatening.