Nokea
The nurse is monitoring a newborn with skin discoloration in the buttock and lumbar area. Which action by the nurse is appropriate?
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- A. Check the newborn's hemoglobin, hematocrit, and platelet levels
- B. Measure and document the size and location of the markings
- C. Notify the registered nurse of the markings immediately
- D. Review the delivery record for evidence of a traumatic birth
Correct Answer: B
Rationale: Skin discoloration in the buttock and lumbar area of a newborn is often due to Mongolian spots (also called congenital dermal melanocytosis). These are benign, flat, bluish-gray patches typically found on the lower back or buttocks. They are more common in infants with darker skin tones and are not harmful, but they can be mistaken for bruises, which raises concern for abuse later on.
The appropriate nursing action is to measure and document the size, shape, and location of the spots in the medical record. This ensures that there is a clear, dated record of the findings to avoid confusion in the future.
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The nurse is caring for a woman whose husband beats her regularly. Which is the most important long-term goal for this woman?
- A. Provide a long-term support group
- B. Help her feel like a survivor
- C. Point out the ways she behaved
- D. Be able to blame the abuser
Correct Answer: B
Rationale: Feeling like a survivor empowers the woman, fostering resilience and self-efficacy, the most important long-term goal in domestic violence recovery.
The nurse is caring for a client who has a prescription for nalbuphine 10 mg/70 kg subcutaneously once. The client weighs 187 lb (85 kg). The nurse has nalbuphine 10 mg/1 mL available. How many mL should the nurse administer to the client? Record your answer using 1 decimal place.
Correct Answer: 1.2
Rationale: Dose = (10 mg/70 kg) × 85 kg = 12.14 mg. Volume = 12.14 mg ÷ 10 mg/mL = 1.2 mL.
The nurse is caring for a client with a feeding tube that has become obstructed. Which intervention should the nurse implement first to unclog the tube?
- A. Flush and aspirate the tube with warm water
- B. Instill a digestive enzyme solution into the tube
- C. Instill cola or cranberry juice into the tube
- D. Use a small barrel syringe to flush the tube
Correct Answer: A
Rationale: Flushing with warm water is the first, safest step to unclog a feeding tube. Enzymes or other solutions are used if water fails, and small syringes may cause excessive pressure.
The nurse is caring for a client who has type 2 diabetes mellitus and an elevated hemoglobin A1c. Which statement by the nurse will best address this result?
- A. It is important for us to review the signs and symptoms of a hypoglycemic reaction.
- B. Let's review your diet, exercise, and medication regimen over the past 2-3 months.
- C. Please describe what you have eaten in the last 24-48 hours.
- D. You should fast for at least 8 hours prior to your morning blood work.
Correct Answer: B
Rationale: Elevated A1c reflects poor glycemic control over months, so reviewing diet, exercise, and medications is most relevant. Other options are less comprehensive.
The mother of a newborn child is very upset. The child has a cleft lip and palate. The type of crisis this mother is experiencing is:
- A. reactive.
- B. maturational.
- C. situational.
- D. adventitious.
Correct Answer: C
Rationale: The arrival of the imperfect child that the mother had not envisioned places the mother in a situational crisis.