Nokea
The nurse is caring for a newborn 12 hours after an uncomplicated vaginal birth at 39 weeks gestation. Which of the following findings would require follow up? Select all that apply.
- A. Plantar creases are present over the entire soles of the feet
- B. Skin on the forehead blanches to a yellowish hue
- C. Toes fan outward as the sole of the foot is stroked upward
- D. Umbilical cord has one artery and one vein
- E. White, pearl-like cysts are present on the gum margins
Correct Answer: B,D
Rationale: Yellowish skin suggests jaundice, which requires monitoring for bilirubin levels. An umbilical cord with one artery (instead of two) and one vein may indicate congenital anomalies, needing further evaluation. Plantar creases are normal at 39 weeks, the Babinski reflex (toes fanning) is expected, and gum cysts (Epstein pearls) are benign.
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The nurse is teaching a teenage female about preventing the transmission of genital herpes. Which of the following statements should the nurse include?
- A. Do not sit on toilet seats without protection.'
- B. Oral sex does not transmit the virus.'
- C. This infection can be transmitted via intercourse even when you do not feel ill.'
- D. Try to drink lots of fluids after sex to flush the reproductive tract.'
Correct Answer: C
Rationale: Genital herpes can be transmitted during asymptomatic periods via sexual contact, including intercourse. The other statements are myths or irrelevant to prevention. Safety and Infection Control
The practical nurse is assisting the registered nurse in performing well-child examinations in a pediatric clinic. Which finding requires further evaluation?
- A. Chest rounded with the anteroposterior diameter equal to the lateral diameter in an infant
- B. Lateral curvature to the spine noted on examination of a 10-year-old girl
- C. Presence of an S3 heart sound in a 2-year-old
Correct Answer: B
Rationale: Lateral curvature of the spine in a 10-year-old suggests scoliosis, which requires further evaluation to prevent progression. A rounded chest in infants is normal due to developing lungs, and an S3 heart sound can be normal in young children.
The nurse is providing diversional activities for a 4-year-old client who is on long-term, strict bed rest. Which of the following toys would be most appropriate to provide for the client?
- A. Card game
- B. Board game
- C. Soap bubbles
- D. Plastic medical kit
Correct Answer: C
Rationale: Soap bubbles are safe, engaging, and can be used while on strict bed rest, promoting activity without physical exertion. Card and board games may require setup or movement, and a medical kit may cause anxiety.
After returning from the postanesthesia care unit, a man who had abdominal surgery is ordered to be in semi-sitting position. What is the primary reason for this position for this client?
- A. To prevent venous stasis
- B. To promote circulation
- C. To reduce tension on the incision
- D. To prevent respiratory distress
Correct Answer: D
Rationale: Semi-sitting position promotes lung expansion, preventing respiratory distress post-abdominal surgery. It has secondary benefits for circulation and incision tension.
The nurse is caring for a client with newly prescribed hearing aids. Which of the following actions by the client indicate proper use and care of hearing aids? Select all that apply.
- A. Keeps hearing aids clean by rinsing them with water
- B. Lowers television volume when talking with nurse
- C. Places hearing aids on food tray when not in use
- D. Turns volume completely down prior to insertion of aid into the ear
- E. Verifies that battery compartment is closed before insertion
Correct Answer: B,D,E
Rationale: Lowering TV volume indicates effective hearing aid use, turning volume down prevents feedback, and verifying the battery compartment ensures functionality. Rinsing with water damages hearing aids, and placing them on a food tray risks contamination or loss.