Nokea
The student nurse has performed a gestational age assessment of an infant and finds the infant to be at 32 weeks. On which set of characteristics is the nurse basing this assessment?
- A. Lanugo mostly gone, little vernix remaining on the body
- B. Prominent clitoris, enlarging labia minora, patent anus
- C. Full areola, 5 to 10 mm nipple bud, pinkish-brown areola
- D. Skin opaque, cracking at wrists and ankles, no visible vessels
Correct Answer: B
Rationale: The correct answer is B. At 30 to 32 weeks' gestation, the clitoris is prominent, and the labia minora are enlarging. The labia majora are small and widely separated. As gestational age increases, the labia majora increase in size. At 36 to 40 weeks, they almost cover the clitoris. At 40 weeks and beyond, the labia majora cover the labia minora and clitoris. Choices A, C, and D do not align with the characteristic features seen at 32 weeks of gestation, making them incorrect.
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When discussing heart conditions, a healthcare provider explains a condition in which the lungs retain extra fluid due to left ventricular impairment. What is this condition?
- A. Whooping cough
- B. Pneumonia
- C. Asthma
- D. Pulmonary edema
Correct Answer: D
Rationale: Pulmonary edema is the correct answer. It is a condition characterized by the retention of extra fluid in the lungs, often due to left ventricular impairment. This fluid buildup can lead to symptoms such as shortness of breath, coughing, and difficulty breathing. Whooping cough (Choice A), pneumonia (Choice B), and asthma (Choice C) are not conditions related to the retention of fluid in the lungs due to left ventricular impairment. Whooping cough is a bacterial respiratory infection, pneumonia is an infection that inflames the air sacs in one or both lungs, and asthma is a chronic respiratory condition characterized by airway inflammation and constriction.
In educating the parents of a child diagnosed with hypothyroidism, the nurse mentions that the child should avoid goitrogens. Which of the following will the nurse mention as an example?
- A. Orange
- B. Tomatoes
- C. Cabbage
- D. Grapes
Correct Answer: C
Rationale: Cabbage is an example of a goitrogen that should be avoided in children with hypothyroidism. Goitrogens are substances that can interfere with thyroid function by inhibiting iodine uptake, potentially worsening the condition. Cabbage, along with other cruciferous vegetables like broccoli and cauliflower, contains compounds that can affect thyroid hormone production. Oranges, tomatoes, and grapes are not classified as goitrogens. Therefore, it is important for parents to be aware of foods like cabbage and to limit their child's intake to help manage their hypothyroidism effectively.
What is the most appropriate action to prevent heat loss in a newborn immediately after birth?
- A. Place the newborn in an incubator
- B. Bathe the newborn right away
- C. Dry the newborn thoroughly
- D. Feed the newborn
Correct Answer: C
Rationale: Drying the newborn thoroughly is the most appropriate action to prevent heat loss immediately after birth. This helps to prevent heat loss through evaporation, which is crucial in maintaining the newborn's body temperature. Placing the newborn in an incubator can be a secondary step after ensuring the baby is dry. Bathing the newborn right away is not recommended as it can lead to further heat loss through evaporation. Feeding the newborn is important but not an immediate action to prevent heat loss; ensuring the baby is dry and warm takes precedence.
The nurse is using the New Ballard Score to assess the gestational age of a newborn delivered 4 hours ago. The infant's gestational age is 33 weeks based on early ultrasound and last menstrual period. The nurse expects the infant to exhibit which of the following?
- A. Full sole creases, nails extending beyond the fingertips, scarf sign showing the elbow beyond the midline
- B. Testes located in the upper scrotum, rugae covering the scrotum, vernix covering the entire body
- C. Ear cartilage folded over, lanugo present over much of the body, slow recoil time
- D. 1 cm breast bud, peeling skin and veins not visible, rapid recoil of legs and arms to extension
Correct Answer: C
Rationale: The correct answer is C. Ear cartilage folded over, lanugo present over much of the body, and slow recoil time are all characteristics of a preterm infant. A is incorrect because full sole creases, nails extending beyond the fingertips, and scarf sign showing the elbow beyond the midline are features of a term infant. B is incorrect as testes located in the upper scrotum, rugae covering the scrotum, and vernix covering the entire body are also indicative of a term infant. D is incorrect because a 1 cm breast bud, peeling skin and veins not visible, and rapid recoil of legs and arms to extension are characteristics seen in a more mature infant, not a preterm newborn.
What intervention should the nurse encourage for a postpartum client complaining of perineal pain?
- A. Use of ice packs for the first 24 hours
- B. Application of heat packs immediately
- C. Avoiding the use of peri-bottles
- D. Using tampons to manage lochia
Correct Answer: A
Rationale: The correct intervention for perineal pain in a postpartum client is the use of ice packs for the first 24 hours. Ice packs help reduce swelling and discomfort in the perineal area, especially during the initial post-delivery period. Applying heat packs can exacerbate swelling and discomfort. Avoiding peri-bottles may lead to poor perineal hygiene. Using tampons is contraindicated postpartum as it increases the risk of infection.