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What is the diameter of fetal skull that presents at vulva during normal labour:
- A. Suboccipitofrontal.
- B. Mentovertical.
- C. Suboccipitobregmatic.
- D. Occipitofrontal.
- E. Metoposterior.
Correct Answer: C
Rationale: In normal vertex presentation the suboccipitobregmatic diameter (9.5 cm) is the smallest and presents at the vulva during delivery. Other diameters are larger or associated with abnormal presentations.
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Of the following methods,the safest,most precise and simplest for placental localization is:
- A. Auscultation.
- B. Ultrasonography.
- C. Radioisotope study.
- D. Abdominal palpation.
- E. Soft tissue radiography.
Correct Answer: B
Rationale: Ultrasonography is the safest most precise and simplest method for placental localization offering real-time imaging without radiation. Other methods are less accurate or involve risks.
Which response by the nurse would be most helpful in this situation?
- A. You should attempt to discuss the dangers of drug abuse with the patient to see if treatment is necessary.
- B. It will be necessary to get a court order before you can force your child to enter a drug treatment program.
- C. The success of the drug treatment program will depend on your child's desire to become drug-free.
- D. It's best that you force your child into the treatment program because otherwise participation probably will not occur.
Correct Answer: C
Rationale: The success of drug treatment relies on the adolescent's motivation to recover, making it important to discuss their willingness and readiness for treatment.
During an assessment of the full-term,1-hour-old newborn the nurse obtains an apical HR of 120 bpm and auscultates a soft murmur at the left sternal border third intercostal space. In response to these assessment findings which action should be taken by the nurse?
- A. Immediately report the findings to the HCP.
- B. Document the heart rate and murmur.
- C. Recheck the murmur in the left side-lying position.
- D. Stimulate crying and then reassess the cardiac status.
Correct Answer: B
Rationale: An apical HR of 120 bpm (normal: 100–160 bpm) and a murmur at the sternal border (likely due to delayed foramen ovale closure) are normal findings. Documentation is sufficient. Reporting repositioning or stimulating crying is unnecessary.
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.
A breastfeeding mother is being discharged with her 2-day-old,full-term newborn. The nurse recognizes that the mother understands how to determine if her newborn is getting enough breast milk when making which statement?
- A. “He should have at least three wet diapers tomorrow.”
- B. “He should have one stool per day during the next week.”
- C. “At his 1-week checkup,he should weigh an additional 8 ounces.”
- D. “He should nurse for 5 minutes on each breast to get enough milk.”
Correct Answer: A
Rationale: A 3-day-old should have at least three wet diapers indicating adequate intake. Breastfed infants stool 3–10 times daily lose 5–10% birth weight initially and nurse 10–20 minutes per breast.