Nokea
The nursery nurse reviews a newborn's birth history and notes that the Apgar scores were 5 at one minute after birth, and 7 at five minutes after birth. How should the nurse interpret these scores? The infant:
- A. Needed brief oral and nasal suctioning.
- B. Required endotracheal intubation and bagging with a hand-held resuscitator.
- C. Was stillborn and required CPR.
- D. Required physical stimulation and supplemental oxygen.
Correct Answer: D
Rationale: The correct answer is D: Required physical stimulation and supplemental oxygen. The Apgar score assesses a newborn's overall condition at birth based on five criteria: heart rate, respiratory effort, muscle tone, reflex irritability, and color. A score of 5 at one minute indicates the infant needed assistance, such as stimulation to breathe and oxygen support. The score of 7 at five minutes shows improvement but still requires some intervention. Choices A, B, and C are incorrect because they suggest more aggressive interventions that are not indicated based on the Apgar scores provided, as the infant's condition was not critical enough to warrant those actions.
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Which of the following are probable signs, strongly indicating pregnancy?
- A. The presence of fetal heart sounds is a positive sign of pregnancy; quickening is a presumptive sign of pregnancy.
- B. These are presumptive signs. They may indicate pregnancy or they may be caused by other conditions, such as disease processes.
- C. Hegar’s sign is a softening of the lower uterine segment, and Chadwick's sign is the bluish or purplish color of the cervix as a result of the increased blood supply and increased estrogen. Ballottement occurs when the cervix is tapped by an examiner's finger and the fetus floats upward in the amniotic fluid and then falls downward.
- D. These are presumptive signs that might indicate pregnancy, but they might be caused by other conditions, such as disease processes.
Correct Answer: C
Rationale: The correct answer is C because Hegar's sign and Chadwick's sign are considered probable signs of pregnancy. Hegar's sign indicates softening of the lower uterine segment, a physiological change that typically occurs in pregnancy. Chadwick's sign refers to the bluish or purplish color of the cervix due to increased blood supply and estrogen levels in pregnancy. These signs are more specific to pregnancy compared to presumptive signs like quickening, which can be caused by other conditions. Ballottement is a technique used to assess fetal movement and position, not a sign indicating pregnancy certainty. Therefore, choices A, B, and D are incorrect as they refer to presumptive signs or signs that could be caused by conditions other than pregnancy.
A nurse is assessing a client who has gestational diabetes and is experiencing hyperglycemia. Which of the following findings should the nurse expect?
- A. Reports increased urinary output
- B. Diaphoresis
- C. Reports blurred vision
- D. Shallow respirations
Correct Answer: A
Rationale: The correct answer is A: Reports increased urinary output. In hyperglycemia, the body tries to eliminate excess glucose through urine, leading to increased urinary output. This is known as osmotic diuresis. Diaphoresis (B) is sweating, which is not typically associated with hyperglycemia. Blurred vision (C) is a symptom of prolonged hyperglycemia affecting the eyes but not an immediate finding. Shallow respirations (D) are not directly related to hyperglycemia.
A child diagnosed with asthma begins corticosteroid treatments. The nurse explains to the parents that the purpose of corticosteroid treatment is to produce which therapeutic effect?
- A. Dilation of bronchial airways
- B. Decrease bronchospasms
- C. Prevention of infection
- D. Anti-inflammatory effect
Correct Answer: D
Rationale: Corticosteroid usage is common for decreasing inflammation of the bronchial airways. While dilation of bronchial airways and decrease in bronchospasms are effects of other medications like albuterol and beta-2 agonists, corticosteroids specifically target inflammation, which is a key component in managing chronic asthma.
Which condition must occur in order for identical (monozygotic) twins to develop?
- A. One sperm fertilizes two ova
- B. Two sperm fertilize two ova
- C. One sperm fertilizes one ovum
- D. Two sperm fertilize one ovum
Correct Answer: C
Rationale: The correct answer is C: One sperm fertilizes one ovum. Identical twins result from the fertilization of a single egg by a single sperm, leading to the formation of a zygote that later splits into two embryos. This process results in genetically identical individuals. Choices A, B, and D involve multiple fertilization events, which would lead to fraternal (dizygotic) twins with different genetic compositions. Therefore, the only condition that can lead to the development of identical twins is when one sperm fertilizes one ovum.
A nurse smells an odor identified as marijuana coming from a room. Which of the following client findings would confirm inhalation of the substance?
- A. Poor coordination, red eyes, and euphoria
- B. Slurred speech, confusion, and combativeness
- C. Loss of consciousness, respiratory depression, and coma
- D. Hypertension, tachycardia, and hyperflexia
Correct Answer: A
Rationale: The correct answer is A because poor coordination, red eyes, and euphoria are classic signs of marijuana inhalation. Poor coordination is a common effect due to impairment of motor skills. Red eyes result from vasodilation caused by marijuana. Euphoria is a psychological effect of the drug. Slurred speech, confusion, and combativeness (Option B) are more indicative of alcohol or sedative use. Loss of consciousness, respiratory depression, and coma (Option C) are severe symptoms more likely associated with opioid or sedative overdose. Hypertension, tachycardia, and hyperflexia (Option D) are not typically seen with marijuana use; they are more consistent with stimulant use.