Nokea
The nurse is caring for a newborn receiving an exchange transfusion for hemolytic disease. Assessment of the newborn reveals slight respiratory distress and tachycardia. Which should the nurse's first action be?
- A. Notify practitioner.
- B. Stop the transfusion.
- C. Administer calcium gluconate.
- D. Monitor vital signs electronically.
Correct Answer: B
Rationale: Slight respiratory distress and tachycardia in a newborn during an exchange transfusion may indicate a possible transfusion reaction or overload. The first action the nurse should take is to stop the transfusion to prevent any further complications and assess the newborn's condition. After stopping the transfusion, the nurse can then take appropriate steps such as notifying the practitioner, administering medications, or providing supportive care as needed.
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The nurse is assessing a 3-day-old, breastfed newborn who weighed 7 pounds, 8 ounces at birth. The newborn's mother is now concerned that the newborn weighs 6 pounds, 15 ounces. Which is the most appropriate nursing intervention?
- A. Recommend supplemental feedings of formula.
- B. Explain that this weight loss is within normal limits.
- C. Assess child further to determine cause of excessive weight loss.
- D. Encourage mother to express breast milk for bottle feeding the newborn.
Correct Answer: B
Rationale: It is normal for newborns to lose weight in the first few days of life, typically up to 10% of their birth weight. In this case, the newborn's weight loss from 7 pounds, 8 ounces to 6 pounds, 15 ounces is within the expected range. It is important for the nurse to reassure the mother that this weight loss is normal and to encourage continued breastfeeding on demand to support newborn hydration and nutrition. There is no need for supplemental feedings at this point unless there are other signs of feeding issues or concerns.
Where do the lesions of atopic dermatitis (eczema) most commonly occur in the infant? (Select all that apply.)
- A. Cheeks
- B. Buttocks
- C. Extensor surfaces of arms and legs
- D. Back
Correct Answer: A
Rationale: In infants with atopic dermatitis (eczema), the lesions most commonly occur on the cheeks (option A) and the extensor surfaces of the arms and legs (option C). The cheeks are a common site of involvement due to increased exposure to irritants and saliva from drooling. The extensor surfaces of the arms and legs are also frequently affected due to scratching and rubbing against clothing. While atopic dermatitis can occur in other areas such as the buttocks, back, and trunk, the cheeks and extensor surfaces are the most common locations in infants.
Extraneural metastasis from primary brain tumors is MOST commonly likely to occur in which tumor?
- A. medulloblastoma
- B. primitive neuroectodermal tumor (PNET)
- C. ependymoma
- D. malignant glioma
Correct Answer: A
Rationale: Medulloblastoma is notorious for extraneural spread, particularly to bones and bone marrow.
An 8-year-old girl asks the nurse how the blood pressure apparatus works. What is the most appropriate nursing action?
- A. Ask her why she wants to know.
- B. Determine why she is so anxious.
- C. Explain in simple terms how it works.
- D. Tell her she will see how it works as it is used.
Correct Answer: C
Rationale: The most appropriate nursing action when an 8-year-old girl asks how the blood pressure apparatus works is to explain in simple terms how it works. Children are curious by nature and providing a simple explanation in a language they can understand helps satisfy their curiosity and also promotes their understanding. By explaining how the blood pressure apparatus works, the nurse can educate the child about a common medical device and reduce any anxiety or fear the child may have about it. This approach encourages the child to feel more comfortable and engaged in their healthcare experience.
the Anti Streptolycin o titer (ASOT) is positive with :
- A. tonsillitis
- B. glomerulonephritis
- C. RF
- D. all the above
Correct Answer: D
Rationale: The Anti Streptolysin O titer (ASOT) is a test used to detect antibodies produced by the body in response to a recent streptococcal infection. A positive ASOT result can be seen in various conditions such as tonsillitis, glomerulonephritis, and Rheumatic fever (RF), which are all associated with streptococcal infections. Therefore, the correct answer is D, as all of these conditions can lead to a positive ASOT result.