Nokea
The parents are visiting their newborn,who is in the neonatal intensive care unit (NICU) after being diagnosed with a terminal cardiac condition. Which statement best reflects the nurse’s judgment about interventions to promote parental attachment?
- A. Interventions should be delayed until it is certain that the newborn will live.
- B. The parents should be encouraged to provide as much care as possible.
- C. The parents should only be encouraged to touch and name their newborn.
- D. The parents should be assured that they did not do anything to cause this condition.
Correct Answer: B
Rationale: Encouraging parents to provide care promotes attachment aiding coping if the infant dies. Delaying interventions limiting to touch/naming or assuming guilt are less supportive.
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The nurse is concerned that a newborn may have congenital hydrocephalus. Which finding did the nurse likely observe on assessment?
- A. Bulging anterior fontanel
- B. Head and chest circumference equal
- C. A narrowed posterior fontanel
- D. Low-set ears
Correct Answer: A
Rationale: A bulging anterior fontanel suggests hydrocephalus due to increased intracranial pressure. Equal head/chest circumferences narrow posterior fontanel and low-set ears are normal or unrelated.
Which finding documented by the nurse is most indicative of a client with rheumatic fever?
- A. Slow, irregular heartbeat
- B. Blotchy, diffuse erythema
- C. Decreased antistreptolysin O titer (ASO titer)
- D. Generalized migrating joint tenderness
Correct Answer: D
Rationale: Generalized migrating joint tenderness (polyarthritis) is a hallmark symptom of rheumatic fever, reflecting the inflammatory process affecting multiple joints. An elevated ASO titer (not decreased) would indicate a recent streptococcal infection, and the other options are less specific.
Which clinical manifestation of the client's full-thickness burns would the nurse detect during an assessment?
- A. Moderate level of pain due to exposed nerve endings
- B. Eschar formation throughout the area of the burn
- C. The appearance of blister formation throughout the area of the burn
- D. Noted tissue destruction extending to the subcutaneous layer
Correct Answer: D
Rationale: Full-thickness burns involve destruction of all skin layers, including the subcutaneous layer, resulting in a leathery or charred appearance. Pain is minimal due to nerve destruction, and blisters are characteristic of partial-thickness burns.
The nurse is administering surfactant via ET tube to a 48-hour-old preterm infant with respiratory distress syndrome (RDS). The father asks the nurse how this treatment will help his baby. The nurse should explain that the preterm infant is unable to produce adequate amounts of surfactant and that giving it to his baby will have what effect?
- A. Increase PaCO2 levels in the bloodstream
- B. Prevent collapse of the alveoli
- C. Decrease PaO2 levels in the bloodstream
- D. Prevent pleural effusion
Correct Answer: B
Rationale: Surfactant prevents alveolar collapse in RDS improving gas exchange decreasing PaCO2 and increasing PaO2. Pleural effusion is unrelated.
The first-time mother of the 2-hour-old full-term newborn worriedly tells the nurse,“Something black is coming out of my baby.” After determining that the newborn has passed stool which statement by the nurse is most appropriate?
- A. “Black stools could be from bleeding. I will notify your provider now.”
- B. “Breastfeeding will cause all the baby’s stools to be this dark in color.”
- C. “Babies normally pass this type of stool initially; it is called meconium.”
- D. “I’ll check the baby’s temperature; this occurs when babies need warming.”
Correct Answer: C
Rationale: Meconium a greenish-black stool is normal within 24 hours after birth formed from amniotic fluid and intestinal secretions. It’s not related to bleeding breastfeeding or temperature.