Nokea
The nurse is teaching a new mother about the physical characteristics and needs of her baby. Which of the following statements should the nurse include in her discussion?
- A. The anterior fontanelle will close by the time the baby is 18 months of age.'
- B. The grasp reflex will last until the baby is about 10 months old.'
- C. Your baby can see shapes but will not be able to see colors clearly for about 6 months.'
- D. Your baby will likely be started on solid foods when he is 2 to 3 months of age.'
Correct Answer: A
Rationale: The anterior fontanelle typically closes by 18 months of age. The other statements are incorrect or misleading.
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A nurse hears a co-worker state that anybody could be a nurse since it is so automated with infusion devices and electronic monitoring; technology is doing the work. What is the nurse’s best response?
- A. Technology use has to be combined with nursing judgment.
- B. The focus of effective nursing care is technology.
- C. If it’s so easy, why don’t you do it?
- D. That is true in the 20th century.
Correct Answer: A
Rationale: In many ways, technology makes work easier, but it does not replace nursing judgment. Technology does not replace your critical eye and clinical judgment. Most importantly, it is essential to remember that the focus of nursing care is not the machine or the technology; it is the patient.
The nurse is caring for a patient whose insurance coverage is Medicare. The nurse should consider which information when planning care for this patient?
- A. Capitation provides the hospital with a means of recovering variable charges.
- B. The hospital will be paid for the full cost of the patient’s hospitalization.
- C. Diagnosis-related groups (DRGs) provide a fixed reimbursement of cost.
- D. Medicare will pay the national average for the patient’s condition.
Correct Answer: C
Rationale: In 1983, Congress established the prospective payment system (PPS), which grouped inpatient hospital services for Medicare patients into diagnosis-related groups (DRGs), each of which provides a fixed reimbursement amount based on assigned DRG, regardless of a patient’s length of stay or use of services.
You are performing assessments for an obstetric patient who is 5 months pregnant with her third child. Which finding would cause you to suspect that the patient was at risk?
- A. Patient states that she doesn't feel any Braxton Hicks contractions like she had in her prior pregnancies.
- B. Fundal height is below the umbilicus.
- C. Cervical changes, such as Goodell's sign and Chadwick's sign, are present.
- D. She has increased vaginal secretions.
Correct Answer: B
Rationale: The correct answer is B: Fundal height is below the umbilicus. At 5 months pregnant with her third child, fundal height should be at or above the level of the umbilicus. A fundal height below the umbilicus may indicate intrauterine growth restriction or other fetal growth issues. This finding suggests a potential risk to the pregnancy's progress.
Incorrect Choices:
A: Patient not feeling Braxton Hicks contractions is common and not necessarily indicative of risk.
C: Presence of cervical changes like Goodell's and Chadwick's signs are expected physiological changes in pregnancy and do not necessarily indicate risk.
D: Increased vaginal secretions can be normal during pregnancy and do not necessarily signify a risk.
A client, 6 cm and 80% effaced, has just received Demerol (meperidine) 50 mg IV for pain. Which of the following fetal heart changes would the nurse expect to observe on the internal fetal monitor tracing?
- A. Drop in baseline heart rate.
- B. Increase in number of variable decelerations.
- C. Decrease in variability.
- D. Rise in number of early decelerations.
Correct Answer: C
Rationale: Demerol can cross the placenta and cause decreased variability in the fetal heart rate.
A client is receiving terbutaline (Brethine) IV for preterm labor. Which of the following maternal findings would warrant stopping the infusion?
- A. Cardiac arrhythmias.
- B. Respiratory rate 24 rpm.
- C. Blood pressure 90/60.
- D. Hypocalcemia.
Correct Answer: A
Rationale: Cardiac arrhythmias are a serious side effect of terbutaline and would warrant stopping the infusion to prevent further complications.