Nokea
A nurse is performing a physical assessment of a newborn. Which of the following clinical findings should the nurse expect? (Select all that apply).
- A. Heart Rate 154/min
- B. Axillary temperature 96.8 F
- C. Respiratory rate 58/min
- D. Length 43 cm (16.9in)
Correct Answer: A,B,C,D
Rationale: The correct answer is A, B, C, and D.
1. Heart rate of 154/min is expected in a newborn, indicating normal cardiac function.
2. Axillary temperature of 96.8 F is within the normal range for a newborn.
3. Respiratory rate of 58/min is expected due to the newborn's immature respiratory system.
4. Length of 43 cm (16.9 in) falls within the normal range for a newborn's size.
Incorrect choices are not applicable due to lack of details, but in general, incorrect options would have included values outside the normal range for a newborn's physical assessment.
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The nurse midwife is concerned about a pregnant client who is suspected of having a TORCH infection. Which is the main reason TORCH infections are grouped together? They are:
- A. benign to the woman but cause death to the fetus.
- B. sexually transmitted.
- C. capable of infecting the fetus.
- D. transmitted to the pregnant woman by a vector.
Correct Answer: C
Rationale: The correct answer is C because TORCH infections (Toxoplasmosis, Other, Rubella, Cytomegalovirus, Herpes) are grouped together due to their ability to infect the fetus during pregnancy. These infections can lead to severe complications in the developing fetus, including congenital disabilities and even fetal death. Choices A, B, and D do not accurately describe the main reason TORCH infections are grouped together. Choice A focuses on the outcomes for the woman and fetus, not the reason for grouping the infections. Choice B is incorrect as TORCH infections are not primarily sexually transmitted. Choice D is also incorrect as TORCH infections are not transmitted by vectors but through various routes such as transplacentally or through contact with infected bodily fluids.
A nurse is caring for an infant with hypospadias. Which of the following is an expected finding?
- A. The meatal opening is on the dorsal surface of the penis.
- B. The urethral opening is on the underside of the penis.
- C. Fluid is present in the scrotal sac containing the testes.
- D. The testes are not palpable within the scrotal sac.
Correct Answer: B
Rationale: Hypospadias involves the urethral opening being located on the underside of the penis.
A new mother is crying in her room. She tells the nurse that her new baby boy has enlarged breasts and she thinks that there is something wrong. How should the nurse respond?
- A. Enlarged breasts are common for both boys and girls. It will go away.
- B. Let me look at the baby for you.
- C. Everything is going to be just fine. Your baby is healthy.
- D. You should ask your doctor about that.
Correct Answer: A
Rationale: The correct answer is A. Enlarged breasts in newborn boys and girls are a common physiological phenomenon called breast engorgement due to maternal hormones. The nurse should reassure the mother that it is normal and will resolve on its own. Choice B is unnecessary as the nurse already knows the cause. Choice C is vague and does not address the mother's concern directly. Choice D is not ideal as the nurse can provide basic information on the issue.
Which of the following approaches is the most accurate way to measure the heart rate of a 10-month-old infant?
- A. "Apical"'
- B. "Radial"'
- C. "Ulna"'
- D. "Brachial"'
Correct Answer: A
Rationale: The correct answer is A: "Apical." This method involves placing the stethoscope over the apex of the heart to directly listen to the heart sounds. In infants, especially 10-month-olds, the apical pulse is more accurate as it allows for a direct assessment of the heart rate without interference from other factors like peripheral pulses. The apical pulse is easier to locate in infants due to their smaller chest size and thinner chest walls. Choices B, C, and D (Radial, Ulna, and Brachial) are incorrect for measuring heart rate in infants as they involve peripheral pulse sites which may not provide an accurate representation of the heart rate due to various factors like weak pulses or difficulty in palpating them accurately in infants.
A nurse is initiating a plan of care for a toddler who is hospitalized. Which of the following instructions is important to communicate to the nursing assistant?
- A. Have the toddler dress himself.
- B. Offer the toddler finger foods for snacks.
- C. Provide opportunities to share toys with others.
- D. Ask the child simple yes or no questions.
Correct Answer: B
Rationale: The correct answer is B: Offer the toddler finger foods for snacks. This instruction is important to communicate to the nursing assistant because toddlers are at risk for choking on certain foods due to their developing chewing and swallowing abilities. Finger foods are safer for toddlers to eat as they are easier to manage and reduce the risk of choking.
Other choices are incorrect because:
A: Having the toddler dress himself may not be appropriate as toddlers may need assistance and supervision due to their limited motor skills.
C: Providing opportunities to share toys with others is important for social development but is not as critical as ensuring the toddler's safety during meal times.
D: Asking the child simple yes or no questions is a good communication strategy but not as essential for the toddler's safety during snack times.