Nokea
What assessment findings can the nurse anticipate?
- A. High blood glucose levels
- B. Weight of 9 pounds or more
- C. Decreased subcutaneous fat
- D. Hypocalcemia
- E. Hyperbilirubinemia
Correct Answer: B,D,E
Rationale: Macrosomic newborns of diabetic mothers often weigh over 9 pounds and are prone to hypocalcemia and hyperbilirubinemia due to metabolic changes.
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What scenario indicates this patient will require RhoGAM administration?
- A. She has had one Rh-negative child and is pregnant with an Rh-negative child.
- B. She has had an Rh-positive infant and is pregnant with an Rh-positive fetus.
- C. She has had an O-negative child and is pregnant with a B-negative child.
- D. She is a primipara with an O-negative child.
Correct Answer: B
Rationale: An Rh-negative mother who has had an Rh-positive child and is pregnant with another Rh-positive fetus requires RhoGAM to prevent antibody formation.
What will the nurse include in the plan of care when caring for an infant with an intracranial hemorrhage?
- A. Keep positioned with head elevated.
- B. Feed slowly to reduce possibility of vomiting.
- C. Stimulate often to maintain level of consciousness.
- D. Hold and coddle frequently to stimulate.
- E. Observe for increased intracranial pressure.
Correct Answer: A,B,E
Rationale: Care includes keeping the head elevated, feeding slowly to prevent vomiting, and monitoring for increased intracranial pressure, while avoiding stimulation.
Postoperative nursing care of the infant following surgical repair of a cleft lip would include:
- A. Feeding the infant with a spoon to avoid sucking
- B. Positioning the infant on the abdomen to facilitate drainage
- C. Applying elbow restraints to protect the surgical area
- D. Providing minimal stimulation to prevent injury to the incision
Correct Answer: C
Rationale: Elbow restraints are used postoperatively to prevent the infant from damaging the surgical area of a cleft lip repair.
The nurse explains that what is the optimal time for testing for phenylketonuria?
- A. In the first 24 hours of life
- B. After 2 to 3 days
- C. At 4 to 6 weeks of age
- D. At 2 months of age
Correct Answer: B
Rationale: Testing for phenylketonuria at 48 to 72 hours allows sufficient protein intake to reduce false-negative results.
What should they be instructed to provide special attention to in regard to the generalized hypotonicity of the child?
- A. Preventing hyperthermia
- B. Respiratory care
- C. Prevention of diarrhea
- D. Incontinence care
Correct Answer: B
Rationale: Generalized hypotonicity in Down syndrome causes mucus accumulation, increasing the risk of respiratory problems.