Nokea
The nurse is measuring both the chest and head circumference during the full-term newborn’s initial assessment. The newborn’s father observes this and asks the nurse why both measurements are necessary. Which explanation is most accurate?
- A. “Comparing the measurements helps determine if there are head or chest size abnormalities.”
- B. “Measuring the head circumference provides information about future intellectual ability.”
- C. “Measuring the newborn’s chest provides needed information when assessing cardiac health.”
- D. “Comparing the head and chest measurements helps to determine future adult body size.”
Correct Answer: A
Rationale: The circumference of the normal newborn’s head is approximately 2 centimeters greater than the chest at birth. Extreme differences may indicate abnormalities like microcephalus or hydrocephalus. Head size doesn’t predict intelligence chest size doesn’t assess cardiac health and measurements don’t predict adult size.
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Which diversional activity suggested by the nurse is most appropriate for the child during the acute phase of rheumatic fever?
- A. Playing with action figures
- B. Playing video games
- C. Reading an adventure story
- D. Pounding wooden pegs with a mallet
Correct Answer: C
Rationale: During the acute phase of rheumatic fever, the child is on bed rest to reduce cardiac workload. Reading an adventure story is a quiet, non-physically demanding activity appropriate for a 7-year-old, promoting rest while keeping the child engaged.
The nurse meets the frantic father at an ED door. He says he just delivered his wife’s full-term newborn in the car when the temperature outside is only 10°F (—12.2°C). In response to the cold environment,the nurse knows that the infant’s body will immediately begin to produce heat by which mechanism?
- A. Shivering
- B. Metabolizing body fat
- C. Dilating surface blood vessels
- D. Decreasing flexion of the extremities
Correct Answer: B
Rationale: When skin receptors of full-term newborns perceive a drop in environmental temperature the sympathetic nervous system is stimulated. This in turn stimulates metabolism of brown fat thus producing heat that is transferred to the peripheral circulation. Shivering is rarely seen in newborns and it does little to produce heat. Newborns conserve heat by constricting not dilating blood vessels. Decreasing flexion promotes heat loss by exposing more skin surface.
After assisting in the delivery of a full-term infant with anencephaly,the parents ask the nurse to explain treatments that might be available for their infant. Which statement should be the basis for the nurse’s response?
- A. Immediate surgery is necessary to repair the congenital defect.
- B. Anencephaly is incompatible with life; only palliative care should be provided.
- C. A shunting procedure will be necessary initially to relieve intracranial pressure.
- D. Antibiotics are needed initially before any treatment is started.
Correct Answer: B
Rationale: Anencephaly lacking cerebral hemispheres and skull is incompatible with life warranting only palliative care. Surgery shunting or antibiotics cannot correct it.
Which statement by the child indicates a need for further teaching about bicycle safety?
- A. I'll wear my helmet whenever I ride my bicycle.
- B. I'll ride my bicycle in the opposite direction of traffic flow.
- C. I'll stop at all intersections and look both ways before proceeding.
- D. I won't ride my bicycle after dark on the street.
Correct Answer: B
Rationale: Riding in the opposite direction of traffic flow is unsafe, increasing collision risk. Bicycles should be ridden with traffic flow, indicating a need for further teaching.
Which nursing action should be avoided when giving care to a child diagnosed with Wilms' tumor?
- A. Palpating the child's abdomen
- B. Collecting a catheterized urine sample
- C. Assessing pupillary reflex with a penlight
- D. Eliciting a patellar reflex with a reflex hammer
Correct Answer: A
Rationale: Palpating the abdomen in a child with Wilms' tumor risks dislodging tumor cells, potentially causing metastasis, and should be avoided to ensure safety.