Nokea
A nurse is collecting data from a newborn.
The nurse should recognize that which of the following images demonstrates a positive Babinski reflex?
- A. Image showing toes fanning out when the sole is stroked.
- B. Image showing the newborn grasping a finger when the palm is touched.
- C. Image showing the newborn turning the head when the cheek is stroked.
- D. Image showing the newborn making stepping movements when held upright.
Correct Answer: A
Rationale: The image showing toes fanning out when the sole of the foot is stroked demonstrates a positive Babinski reflex, a normal newborn response indicating immature nervous system development.
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A nurse is reinforcing discharge instructions about breastfeeding with a client.
Which of the following statements should the nurse make?
- A. You should recognize that your baby sucking on his hands is a hunger cue.
- B. You should feed your baby six times a day.
- C. You should feed your baby for 10 minutes on each breast.
- D. You should wake your baby at least every 6 hours at night for feedings.
Correct Answer: A
Rationale: Recognizing hand-sucking as a hunger cue ensures timely feeding, critical for establishing successful breastfeeding.
A nurse is assisting with the care of a newborn who has neonatal abstinence syndrome.
Which of the following actions should the nurse take first?
- A. Swaddle the newborn in blankets.
- B. Weigh the newborn's wet diaper.
- C. Auscultate the newborn's bowel sounds.
- D. Determine the newborn's respiratory rate.
Correct Answer: D
Rationale: Determining the respiratory rate first ensures airway and breathing stability, a critical initial step in managing neonatal abstinence syndrome.
A nurse is reinforcing teaching about outpatient resources for a client who is recovering from a molar pregnancy.
Which of the following statements by the client indicates an understanding of the teaching?
- A. I will need to start chemotherapy immediately.
- B. I will need home palliative services after I am discharged.
- C. I will need to attend a support group when I get home.
- D. I will need an amniocentesis within 1 month.
Correct Answer: C
Rationale: Attending a support group aids emotional recovery after a molar pregnancy, indicating understanding of psychosocial support needs.
The nurse should first address the client's blood pressure followed by the client's platelet count.
Which of the following options correctly prioritizes these actions?
- A. Blood pressure should be checked before platelet count.
- B. Platelet count is more important than blood pressure.
- C. Address both simultaneously.
- D. Ignore blood pressure.
Correct Answer: A
Rationale: Blood pressure should be checked first as it indicates immediate hemodynamic status, critical in acute settings, followed by platelet count for bleeding risk.
A nurse is reinforcing teaching with a newly licensed nurse concerning a client on a postpartum unit following a cesarean birth.
Which of the following measures should the nurse include in the instructions to prevent thrombophlebitis?
- A. Have the client ambulate as often as possible.
- B. Apply warm, moist packs to the client's lower legs.
- C. Apply elastic stockings before the client gets out of bed.
- D. Administer NSAIDs every 4 to 6 hours.
Correct Answer: A
Rationale: Encouraging ambulation stimulates circulation, preventing blood clots and reducing thrombophlebitis risk post-cesarean.