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The nurse is presenting an in-service session on assessing gestational age in newborns. Which information should be included?
- A. The newborn's length and weight are the most accurate indicators of gestational age.
- B. The newborn's Apgar score and the mother's estimated date of confinement (EDC) are combined to determine gestational age.
- C. The newborn's posture at rest and arm recoil are two physical signs used to determine gestational age.
- D. The newborn's chest circumference compared to the head circumference is the determinant for gestational age.
Correct Answer: C
Rationale: The newborn's posture at rest and arm recoil are two physical signs used to determine gestational age. Assessment of posture at rest involves observing the newborn's flexed or extended posture when lying flat on their back. Premature infants tend to have more flexed postures due to their immature muscular tone. Arm recoil refers to the ability of the newborn to return their extended arm flexes to the flexed position. This reflex is typically present in more mature infants. These physical signs, along with other factors such as skin texture, breast development, and ear formation, are used by healthcare providers to estimate the gestational age of newborns. While length, weight, and head circumference are also important measurements, the posture at rest and arm recoil are specifically used in determining gestational age.
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A client with Addison's disease comes to the clinic for a follow-up visit. When assessing this client, the nurse should stay alert for signs and symptoms of:
- A. calcium and phosphorus abnormalities
- B. sodium and chloride abnormalities
- C. chloride and magnesium
- D. sodium and potassium abnormalities abnormalities.
Correct Answer: D
Rationale: Addison's disease, also known as adrenal insufficiency, is a condition where the adrenal glands do not produce enough hormones. One of the primary functions of the adrenal glands is to regulate sodium and potassium levels in the body. In Addison's disease, the lack of adrenal hormones can lead to electrolyte imbalances, specifically low sodium levels (hyponatremia) and high potassium levels (hyperkalemia).
Which food is recommended for the patient who must increase intake of potassium?
- A. Bread
- B. Potato
- C. Egg
- D. Cereal
Correct Answer: B
Rationale: Potassium is an essential mineral that plays a key role in numerous bodily functions, including muscle contractions and maintaining proper heart function. Among the options given, potatoes are an excellent source of potassium. One medium-sized potato can provide around 900 mg of potassium, making it a great choice for individuals who need to increase their potassium intake. Therefore, potatoes are recommended for the patient who must increase their intake of potassium.
Which of the following respiratory conditions is always considered a medical emergency?
- A. Asthma
- B. Cystic fibrosis (CF)
- C. Epiglottiditis
- D. Laryngotracheobronchitis (LTB)
Correct Answer: C
Rationale: Epiglottiditis is always considered a medical emergency due to the potential risk of airway obstruction. The epiglottis is a flap of tissue that prevents food and liquids from entering the airway during swallowing. If the epiglottis becomes inflamed or infected, it can swell and block the airway, making it difficult or impossible for the person to breathe. This obstruction can rapidly progress to a life-threatening situation if not treated promptly. Therefore, epiglottiditis requires immediate medical attention to ensure the airway remains open and the individual can breathe properly.
A nurse is assigned to four children of different ages. In which age group should the nurse understand that body integrity is a concern? TestBankWorld.org
- A. Toddler
- B. Preschooler
- C. School-age child
- D. Adolescent
Correct Answer: D
Rationale: Body integrity becomes a concern in adolescence, which is the period of development marked by rapid physical changes and self-awareness. Adolescents may experience body image issues, peer pressure, and the desire to conform to societal standards, which can lead to behaviors that compromise their body integrity, such as risky behaviors, eating disorders, self-harm, or seeking cosmetic procedures. By understanding the concerns surrounding body integrity in adolescents, the nurse can provide appropriate support, education, and guidance to promote healthy body image and self-esteem.
The multilumen pulmonary artery catheter allows the nurse to measure hemodynamic pressures at different points in the heart. When the tip enters the small branches of the pulmonary artery, the nurse can assess all of the following except:
- A. Central venous pressure (CVP)
- B. Pulmonary artery capillary pressure (PACP)
- C. Pulmonary artery obstructive pressure (PACP)
- D. Pulmonary artery wedge pressure (PAWP)
Correct Answer: C
Rationale: The multilumen pulmonary artery catheter, when positioned in the small branches of the pulmonary artery, allows the nurse to measure various hemodynamic pressures. Central venous pressure (CVP), Pulmonary artery capillary pressure (PACP), and Pulmonary artery wedge pressure (PAWP) can be measured accurately at this point. However, "Pulmonary artery obstructive pressure" is not a valid or recognized hemodynamic pressure parameter. Instead, the correct term for this measurement that can be assessed using the catheter is the Pulmonary artery occlusion pressure (PAOP) or Pulmonary artery wedge pressure (PAWP), which reflects the left atrial pressure.