Nokea
The nurse is performing a gestational age assessment on a newborn delivered 2 hours ago. When coming to a conclusion using the Ballard scale, which of these factors may affect the score?
- A. Birth weight
- B. Racial differences
- C. Fetal distress in labor
- D. Birth trauma
Correct Answer: C
Rationale: Fetal distress in labor. The effects of earlier distress may alter the findings of reflex responses as measured on the Ballard tool. Other physical characteristics that estimate gestational age, such as amount of lanugo, sole creases and ear cartilage are unaffected by the other factors.
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When interviewing the parents of a child with asthma, it is most important to assess the child's environment for what factor?
- A. Household pets
- B. New furniture
- C. Lead based paint
- D. Plants such as cactus
Correct Answer: A
Rationale: Animal dander is a very common allergen affecting persons with asthma. Other triggers may include pollens, carpeting and household dust.
When the nurse is caring for a client receiving a neuroleptic medication exhibiting torticollis and involuntary muscle movement, what is the priority nursing action?
- A. Have respiratory support equipment available
- B. Administer an antiemetic medication
- C. Monitor the client’s temperature closely
- D. Administer an antihistamine
Correct Answer: A
Rationale: Have respiratory support equipment available. These side effects could lead to respiratory failure, necessitating immediate respiratory support.
The nurse observes a client self-administering nasal fluticasone. Which observation would require the practical nurse to intervene and reinforce the instructions provided by the registered nurse?
- A. A sitting position is assumed as the head is bowed slightly forward
- B. The client points the spray tip toward the nasal septum during instillation
- C. The nasal spray tip is inserted into the nostril as the other nostril is occluded
- D. While administering the medication, the client inhales deeply through the nose
Correct Answer: B
Rationale: Pointing fluticasone toward the nasal septum risks irritation or bleeding; it should be aimed laterally. Sitting with head forward, occluding the other nostril, and inhaling deeply are correct administration techniques.
While planning care for a toddler, the nurse teaches the parents about the expected developmental changes for this age. Which statement by the mother shows that she understands the child's developmental needs?
- A. I want to protect my child from any falls.'
- B. I will set limits on exploring the house.'
- C. I understand our child's need to use those new skills.'
- D. I intend to keep control over our child's behavior.'
Correct Answer: C
Rationale: I understand our child's need to use those new skills.' Erikson describes the stage of the toddler as being the time when there is normally an increase in autonomy. The child needs to use motor skills to explore the environment.
A couple asks the nurse about risks of several birth control methods. What is the most appropriate response by the nurse?
- A. Norplant is safe and may be removed easily
- B. Oral contraceptives should not be used by smokers
- C. Depo-Provera is convenient with few side effects
- D. The IUD gives protection from pregnancy and infection
Correct Answer: B
Rationale: Oral contraceptives should not be used by smokers. The use of oral contraceptives in a woman who smokes increases her risk of cardiovascular problems, such as thromboembolic disorders.