Nokea
The nurse is caring for the newborn infant. The nurse should prepare to assess the newborn’s anterior fontanel by which method?
- A. Lay the infant on his or her back.
- B. Stimulate the infant to cry strongly.
- C. Feel near the parietal and occipital bones.
- D. Place the infant in a sitting position.
Correct Answer: D
Rationale: The anterior fontanel is assessed with the infant in a sitting position (45°–90°) to evaluate size and abnormalities. Supine positioning or crying may cause bulging and parietal/occipital bones locate the posterior fontanel.
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What information regarding the dangers of tattooing should the nurse provide for this client? Select all that apply.
- A. Tattooing can lead to skin cancer.
- B. There can be an allergic reaction to the tattoo ink.
- C. Tattooing can result in skin infections.
- D. There is a risk for contracting hepatitis B and human immunodeficiency virus (HIV) if dirty needles are used in tattooing.
- E. Tattooing can cause spontaneous abortions in pregnant women.
- F. Tattooing can result in heart and lung conditions.
Correct Answer: B,C,D
Rationale: Tattooing risks include allergic reactions to ink, skin infections from unsterile equipment, and bloodborne infections like hepatitis B and HIV from contaminated needles. Skin cancer, abortions, and heart/lung conditions are not directly linked.
Because the burned child is confined to bed, the nurse assesses for footdrop. Which nursing action best prevents call the development of footdrop?
- A. Apply braces to the feet and ankles.
- B. Keep the child in the side-lying position.
- C. Keep sheets tucked in at the foot of the bed.
- D. Rest the child's feet against a footboard.
Correct Answer: D
Rationale: Resting the child's feet against a footboard maintains a neutral position, preventing plantar flexion and footdrop during prolonged bed rest.
The nurse is assessing the infant who may have FAS. Which findings,if observed,should the nurse associate with FAS? Select all that apply.
- A. Broad nasal bridge and flat midface
- B. Growth deficit in weight and length
- C. Excessive irritability and hypotonia
- D. Poor feeding and persistent vomiting
- E. Large jaw and overdeveloped maxilla
Correct Answer: A,B,C,D
Rationale: FAS features include broad nasal bridge flat midface growth deficits irritability hypotonia and poor feeding/vomiting due to alcohol’s effects. The jaw is small not large.
The physician orders I.V. insulin, and the registered nurse (RN) prepares to give it. The licensed practical nurse (LPN) is assisting the RN with the unstable client. Which of the following types of insulin should the LPN anticipate that the physician will order?
- A. Regular insulin (Humulin R)
- B. Isophane insulin suspension (Humulin N)
- C. Insulin aspart (NovoLog)
- D. None of the above
Correct Answer: A
Rationale: Regular insulin (Humulin R) is used for I.V. administration in DKA because it has a rapid onset and can be titrated to manage hyperglycemia effectively. Other insulins, like NPH or aspart, are not suitable for I.V. use.
Which of the following findings during a routine wellness checkup best indicates that a child has iron deficiency anemia?
- A. Weight gain and hypertension
- B. Nervousness and diarrhea
- C. Nausea and vomiting
- D. Pallor and listlessness
Correct Answer: D
Rationale: Pallor and listlessness are hallmark signs of iron deficiency anemia due to reduced hemoglobin, leading to decreased oxygen delivery and fatigue.