Nokea
When assessing an 18-month old, the nurse notes a characteristics protruding abdomen. Which of the following would explain the rationale for this findings?
- A. Increased food intake owing to age
- B. Underdeveloped abdominal muscles
- C. Bowlegged posture
- D. Linear growth curve
Correct Answer: B
Rationale: Underdeveloped abdominal muscles cause the protruding abdomen typical in toddlers.
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The nurse is preparing to administer vaccines to a 4-month-old infant. Which vaccines should the nurse prepare? (Select one that does not apply.)
- A. DTaP
- B. MMR
- C. IPV
- D. Hib
Correct Answer: B
Rationale: At 4 months, per CDC guidelines, infants receive DTaP (diphtheria, tetanus, pertussis), IPV (inactivated poliovirus), and Hib (Haemophilus influenzae type b). MMR and Varicella are typically given at 12-15 months.
In a routine prenatal visit, the nurse examining a patient who is 37 weeks pregnant notices that the fetal heart rate (FHR) has dropped to 120 beats/min from a rate of 160 beats/min earlier in the pregnancy. What is the nurses first action?
- A. Ask if the patient has taken a sedative.
- B. Notify the physician.
- C. Turn the patient to her right side.
- D. Record the rate as a normal finding.
Correct Answer: D
Rationale: The FHR at term ranges from a low of 110 to 120 beats/min to a high of 150 to 160 beats/min. This should be recorded as normal. The FHR drops in the late stages of pregnancy.
Which hormone initiates the maturation of the ovarian follicle?
- A. Estrogen
- B. Follicle-stimulating hormone
- C. Progesterone
- D. Luteinizing hormone
Correct Answer: B
Rationale: Follicle-stimulating hormone (FSH) stimulates the maturation of a follicle.
An urban area has been reported to have a high perinatal mortality rate. What information does this provide?
- A. Maternal and infant deaths per 100,000 live births per year
- B. Deaths of fetuses weighing more than $500 \mathrm{~g}$ per 10,000 births per year
- C. Deaths of infants up to 1 year of age per 1000 live births per year
- D. Fetal and neonatal deaths per 1000 live births per year
Correct Answer: D
Rationale: The perinatal mortality rate includes fetal and neonatal deaths per 1000 live births per year.
A hospitalized school age states: 'I'm not afraid of this place, I'm not afraid of anything.' This statement is most likely an example of which of the following?
- A. Regression
- B. Repression
- C. Reaction formation
- D. Rationalization
Correct Answer: C
Rationale: Reaction formation involves expressing the opposite of true feelings to cope; the child’s bold statement likely masks fear, typical in school-age children facing hospitalization.