Nokea
The nurse is performing an assessment on a postterm infant. Which physical characteristic should the nurse expect to observe in this infant?
- A. Peeling of the skin
- B. Smooth soles without creases
- C. Lanugo covering the entire body
- D. Vernix that covers the body in a thick layer
Correct Answer: A
Rationale: The postterm infant (born after the 42nd week of gestation) exhibits dry, peeling, cracked, almost leather-like skin over the body, which is called desquamation. The preterm infant (born between 24 and 37 weeks of gestation) exhibits smooth soles without creases, lanugo covering the entire body, and thick vernix covering the body.
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A client is experiencing pulmonary edema as an exacerbation of chronic left-sided heart failure. The nurse should assess the client for what manifestation?
- A. Weight loss
- B. Bilateral crackles
- C. Distended neck veins
- D. Peripheral pitting edema
Correct Answer: B
Rationale: The client with pulmonary edema presents primarily with symptoms that are respiratory in nature because the blood flow is stagnant in the lungs, which lie behind the left side of the heart from a circulatory standpoint. The client would experience weight gain from fluid retention, not weight loss. Distended neck veins and peripheral pitting edema are classic signs of right-sided heart failure.
The nurse assesses the client diagnosed with acquired immunodeficiency syndrome (AIDS) for early signs of Kaposi's sarcoma. What characteristics would be consistent with that lesion? Select all that apply.
- A. Flat
- B. Raised
- C. Resembling a blister
- D. Light blue in color
- E. Brownish and scaly in appearance
- F. Color varies from pink to dark violet or black
Correct Answer: A,F
Rationale: Kaposi's sarcoma generally starts with an area that is flat and pink that changes to a dark violet or black color. The lesions are usually present bilaterally. They may appear in many areas of the body and are treated with radiation, chemotherapy, and cryotherapy. None of the other options are associated with this type of lesion.
A pregnant client at 32 weeks' gestation is admitted to the obstetrical unit for observation after a motor vehicle crash. When the client begins experiencing slight vaginal bleeding and mild cramps, which action should the nurse take to support the viability of the fetus?
- A. Insert an intravenous line and begin an infusion at 125 mL per hour.
- B. Administer oxygen to the woman via a face mask at 7 to 10 L per minute.
- C. Position and connect the ultrasound transducer to the external fetal monitor.
- D. Position and connect a spiral electrode to the fetal monitor for internal fetal monitoring.
Correct Answer: C
Rationale: External fetal monitoring will allow the nurse to determine any change in the fetal heart rate and rhythm that would indicate that the fetus is in jeopardy. The amount of bleeding described is insufficient to require intravenous fluid replacement. Because fetal distress has not been determined at this time, oxygen administration is premature. Internal monitoring is contraindicated when there is vaginal bleeding, especially in preterm labor.
A 2-year-old toddler has just returned from surgery where a hip spica cast was applied. Which nursing action will best maintain the child's skin integrity?
- A. Changing the toddler's diapers every 2 hours.
- B. Keeping the toddler's genital area open to the air.
- C. Implementing a 3-hour turning schedule for the toddler.
- D. Assessing the toddler's perineal area for redness regularly.
Correct Answer: A
Rationale: The spica cast is often needed to treat developmental hip dysplasia (DDH) or after hip/pelvis surgery. The cast encases the child's trunk and one or both legs while leaving access to the genital. Considering the age of the child, diapers will be in use and will need to be changed at least every 2 hours during the day and 3 to 4 hours during the night to help minimize the effect of urine and feces on the child's diaper area. Exposing the genital and perineal area to the air is an intervention that is implemented to assist in healing damaged skin tissue. Turning the child regularly is appropriate care but has no impact on the major issue of incontinence. Assessment of the skin is necessary but identifies skin breakdown once it has begun.
Twelve hours after delivery, the nurse assesses the client for uterine involution. The nurse determines that the uterus is progressing normally toward its prepregnancy state when palpation of the client's fundus is at which level?
- A. At the umbilicus
- B. One finger breadth below the umbilicus
- C. Two finger breadths below the umbilicus
- D. Midway between the umbilicus and the symphysis pubis
Correct Answer: A
Rationale: The term 'involution' is used to describe the rapid reduction in size and the return of the uterus to a normal condition similar to its nonpregnant state. Immediately after the delivery of the placenta, the uterus contracts to the size of a large grapefruit. The fundus is situated in the midline between the symphysis pubis and the umbilicus. Within 6 to 12 hours after birth, the fundus of the uterus rises to the level of the umbilicus. The top of the fundus remains at the level of the umbilicus for about a day and then descends into the pelvis approximately one finger breadth on each succeeding day.