Nokea
What is the most appropriate action for a nurse when a newborn has jaundice on the second day of life?
- A. Increase fluid intake of the mother
- B. Phototherapy
- C. Monitor bilirubin levels
- D. Refer to a pediatric specialist
Correct Answer: B
Rationale: Phototherapy helps treat jaundice by breaking down bilirubin.
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Which of the following interpretations of this finding should the nurse make?
- A. The presenting part is 1 cm above the ischial spines.
- B. The presenting part is 1 cm below the ischial spines.
- C. The cervix is 1 cm dilated.
- D. The cervix is effaced 1 cm.
Correct Answer: A
Rationale: The finding of "station -1" indicates that the presenting part of the baby is 1 cm above the ischial spines in the mother's pelvis. Station is a measurement used in obstetrics to describe the position of the presenting part of the fetus in relation to the ischial spines of the mother's pelvis during labor. Stations are measured in centimeters and range from -5 (highest) to +5 (lowest). In this case, a station of -1 means the baby's presenting part is 1 cm above the ischial spines. This information helps healthcare providers assess the progress of labor and determine the positioning of the baby during delivery.
Which data in the patient's history should the nurse recognize as being pertinent to a possible diagnosis of postpartum depression?
- A. Previous depressive episode
- B. Unexpected operative birth
- C. Ambivalence during the first trimester
- D. Second pregnancy in a 3-year period
Correct Answer: A
Rationale: A previous history of depression is a significant risk factor for postpartum depression. Women who have experienced a depressive episode in the past are more likely to develop postpartum depression compared to those without such a history. Recognizing this pertinent data in the patient's history can help the nurse identify individuals at higher risk for postpartum depression and provide appropriate support and intervention. The other options mentioned (B. Unexpected operative birth, C. Ambivalence during the first trimester, D. Second pregnancy in a 3-year period) may also contribute to emotional distress but are not as directly linked to postpartum depression as a previous depressive episode.
A healthcare professional is reviewing the laboratory values of a client who has respiratory acidosis. Which of the following findings should the healthcare professional expect?
- A. HCO3- 30 mEq/L
- B. PaCO2 50 mm Hg
- C. pH 7.45
- D. Potassium 3.3 mEq/L
Correct Answer: B
Rationale: In respiratory acidosis, the primary disturbance is an increase in PaCO2 levels above the normal range of 35-45 mm Hg. Option B, PaCO2 50 mm Hg, indicates an elevated partial pressure of carbon dioxide, which is consistent with respiratory acidosis. Options A, C, and D are not directly indicative of respiratory acidosis. HCO3- (Option A) is more related to metabolic acidosis or alkalosis, pH (Option C) is within the normal range indicating no acid-base imbalance, and potassium (Option D) levels are not specific to respiratory acidosis.
How should a nurse educate a mother about kangaroo care for her preterm infant?
- A. Encourage frequent visits to the NICU
- B. Educate about skin-to-skin contact benefits
- C. Explain the importance of bonding
- D. Teach the mother about safe handling of the newborn
Correct Answer: B
Rationale: Kangaroo care promotes bonding and regulates temperature for preterm infants.
Which of the following is an abnormal finding upon
- A. To monitor hydration status physical examination of an infant?
- B. To reduce the risk of bladder injury
- C. Anterior fontanel that has a diamond-shaped open
- D. To prevent the patient from urinating during space surgery
Correct Answer: D
Rationale: The abnormal finding listed in option D, "To prevent the patient from urinating during space surgery," stands out from the rest of the options provided. This is because during space surgery, it is not necessary or appropriate to prevent the patient from urinating; rather, it is essential to focus on the surgical procedure and the patient's safety in a space environment. The other options focus on normal or abnormal physical examination findings in infants, such as the hydration status, fontanel appearance, suture line spacing, ear positioning, and uterus displacement.