Nokea
When assessing the infant undergoing phototherapy for hyperbilirubinemia,the nurse notes a maculopapular rash over the infant’s buttocks and back. What action should the nurse take next?
- A. Document the results in the newborn’s medical record.
- B. Call the HCP immediately to report this finding.
- C. Discontinue the phototherapy immediately.
- D. Assess the infant’s axillary temperature.
Correct Answer: A
Rationale: A transient maculopapular rash is a common benign side effect of phototherapy requiring only documentation. No further action is needed.
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Which assessment finding may indicate a serious neurovascular problem that should be reported immediately to the charge nurse or physician?
- A. The toes of the left foot are warmer than the toes of the right foot.
- B. The toes of both feet are cool to the touch.
- C. The child is unable to wiggle the toes of the right foot.
- D. The capillary refill in the toes of the right foot is 2 seconds.
Correct Answer: C
Rationale: Inability to wiggle toes suggests neurovascular compromise, such as nerve or vascular injury, requiring immediate reporting to prevent permanent damage.
23 years old primigravida presents to you at fourteen weeks of gestation. She is concerned about normality of fetus. At what time you will advice her detailed fetal anomaly scan:
- A. 22-24 weeks.
- B. 14-16 weeks.
- C. 18-22 weeks.
- D. 10-14 weeks.
- E. 24-28 weeks.
Correct Answer: C
Rationale: A detailed fetal anomaly scan is typically performed between 18-22 weeks of gestation as this is the optimal time to visualize fetal anatomy clearly. Earlier scans (10-14 weeks) are for nuchal translucency and later scans may miss the window for detailed structural assessment.
Which nursing instruction is correct for the parents of a child who has a vitamin D deficiency?
- A. Give the child cod liver oil daily.
- B. Give the child orange juice daily.
- C. Apply sunblock to the child before sun exposure.
- D. Keep the child indoors during daylight hours.
Correct Answer: A
Rationale: Cod liver oil is a rich source of vitamin D, essential for correcting vitamin D deficiency and supporting bone health.
Which of the following test is used in screening for Down's syndrome:
- A. Ca 125.
- B. Carcino embryonic antigen CAE.
- C. Triple screening including β HCG,AFP,serum estriol.
- D. FSH,LH.
- E. Thyroid hormone.
Correct Answer: C
Rationale: The triple screen (β-hCG AFP serum estriol) is used in the second trimester to screen for Down syndrome. Other tests are not relevant for this purpose.
The nurse evaluates that the newborn’s Moro reflex is WNL. Which response by the newborn prompted the nurse’s conclusion?
- A. Straightens extremities and then flexes them in response to a loud noise
- B. Right-side extremity extension when the head is quickly turned right
- C. Turns the head toward the right side when the right cheek is touched
- D. Attempts to walk when the sole of the foot touches a hard surface
Correct Answer: A
Rationale: An intact Moro reflex involves extremity extension then flexion in response to a loud noise. Other options describe tonic neck rooting and stepping reflexes.