Nokea
The nurse is concerned that a newborn may have congenital hydrocephalus. Which finding did the nurse likely observe on assessment?
- A. Bulging anterior fontanel
- B. Head and chest circumference equal
- C. A narrowed posterior fontanel
- D. Low-set ears
Correct Answer: A
Rationale: A bulging anterior fontanel suggests hydrocephalus due to increased intracranial pressure. Equal head/chest circumferences narrow posterior fontanel and low-set ears are normal or unrelated.
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Which statement by the parents best indicates that the nurse's teaching has been effective?
- A. We'll give our child the penicillin for the full 10 days.
- B. We will keep our child at home until fully recovered.
- C. We will make sure that our child stays out of the sun with being treated.
- D. We'll notify the physician if our child has a sore throat.
Correct Answer: D
Rationale: Effective teaching about rheumatic fever emphasizes preventing recurrent streptococcal infections, which can trigger relapse. Notifying the physician about a sore throat ensures prompt treatment of potential streptococcal infections, reducing recurrence risk.
The nurse is administering surfactant via ET tube to a 48-hour-old preterm infant with respiratory distress syndrome (RDS). The father asks the nurse how this treatment will help his baby. The nurse should explain that the preterm infant is unable to produce adequate amounts of surfactant and that giving it to his baby will have what effect?
- A. Increase PaCO2 levels in the bloodstream
- B. Prevent collapse of the alveoli
- C. Decrease PaO2 levels in the bloodstream
- D. Prevent pleural effusion
Correct Answer: B
Rationale: Surfactant prevents alveolar collapse in RDS improving gas exchange decreasing PaCO2 and increasing PaO2. Pleural effusion is unrelated.
The nurse reviews the labor and delivery record of the 2-hour-old male newborn and sees this notation: “40 weeks’ gestation,large for gestational (LGA) age.” In response to this information it is most important for the nurse to plan to assess the infant carefully for which condition?
- A. Acrocyanosis
- B. Undescended testicles
- C. Intact clavicles
- D. Hypothermia
Correct Answer: C
Rationale: LGA infants risk birth trauma like fractured clavicles due to macrosomia. Acrocyanosis is normal testicles are typically descended at term and LGA infants are less prone to hypothermia.
Duration of latent phase in a multigravida is:
- A. 1-2 hours.
- B. 2-4 hours.
- C. 4-6 hours.
- D. 6-8 hours.
- E. 8-10 hours.
Correct Answer: C
Rationale: The latent phase in multigravida typically lasts 4-6 hours shorter than in primigravida due to prior cervical changes. Other durations are less common.
Which assessment finding should the nurse report immediately to the charge nurse or physician?
- A. Clear, watery nasal drainage
- B. Glasgow Coma Scale score of 15
- C. Child does not know the time of day
- D. Apical pulse of 80 beats/minute
Correct Answer: A
Rationale: Clear, watery nasal drainage may indicate cerebrospinal fluid (CSF) leakage, a serious complication of head injury requiring immediate reporting to prevent infection or neurological damage.