Nokea
The nurse is reviewing the following labor history of a postpartum mother: “Mother positive for group B streptococcal (GBS) infection at 37 weeks’ gestation. Membranes ruptured at home 14 hours before presentation to the hospital at 40 weeks’ gestation. Precipitous labor,no antibiotic given.” Considering this information the nurse should observe her 15-hour-old newborn closely for which finding?
- A. Temperature instability
- B. Pink stains in the diaper
- C. Meconium stools
- D. Presence of erythema toxicum
Correct Answer: A
Rationale: GBS infection risk increases with prolonged membrane rupture and no antibiotics with temperature instability as an early symptom. Pink stains meconium and erythema toxicum are normal.
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Which of the following statements made by the adolescent best supports the nurse's suspicion of scoliosis?
- A. My friends are getting taller faster than I am.
- B. One of my sleeves is always shorter than the other.
- C. I have a difficult time sleeping on my side at night.
- D. I have a difficult time sleeping on my side at night.
Correct Answer: B
Rationale: Uneven sleeve length suggests shoulder asymmetry, a common sign of scoliosis due to lateral spinal curvature affecting posture.
If the nurse documents all the following data, which finding should be reported immediately?
- A. Refusal to eat
- B. Complaint of nausea
- C. Absent bowel sounds
- D. Temperature of 101°F (38.3°C) orally
Correct Answer: C
Rationale: Absent bowel sounds may indicate peritonitis or bowel obstruction, serious complications of appendicitis requiring immediate reporting to prevent further deterioration.
Which nursing action would best promote the adolescent's compliance with wearing the brace?
- A. Advising the parents to keep a constant watch on their daughter to make sure she wears her brace
- B. Suggesting that the parents help their daughter find stylish clothing that will hide the brace
- C. Telling the parents that it might be best to arrange for a homebound teacher
- D. Advising the parents to limit their daughter's participation in school activities
Correct Answer: B
Rationale: Helping the adolescent find stylish clothing to conceal the brace addresses body image concerns, promoting compliance by making the brace less noticeable.
The full-term newborn is placed under phototherapy lights to treat hyperbilirubinemia. The nurse should assess the newborn for dehydration due to which effect of phototherapy?
- A. Decreases sodium absorption
- B. Increases absorption of bilirubin
- C. Decreases urinary output
- D. Increases insensible water loss
Correct Answer: D
Rationale: Phototherapy increases insensible water loss risking dehydration. It breaks down bilirubin for excretion not absorption and doesn’t directly affect sodium or urinary output.
The nurse advises the parents that, to detect possible complications of juvenile rheumatoid arthritis, the child will require which periodic evaluation?
- A. Chest X-rays
- B. Dental examinations
- C. Hearing examinations
- D. Eye examinations
Correct Answer: D
Rationale: JRA can cause uveitis, an eye inflammation that may lead to vision loss if untreated. Periodic eye examinations are essential to detect this complication early.