Nokea
Which are clinical manifestations of the postterm newborn? (Select all that apply.)
- A. Excessive lanugo
- B. Increased subcutaneous fat
- C. Absence of scalp hair
- D. Parchment-like skin
Correct Answer: D
Rationale: Postterm newborns are infants born after 42 weeks of gestation. Some common clinical manifestations of postterm newborns include parchment-like, wrinkled skin due to prolonged exposure to amniotic fluid, and long fingernails as a result of intrauterine growth beyond the expected term. Excessive lanugo and absence of scalp hair are not typically seen in postterm newborns. Increased subcutaneous fat may be more common in infants born at term or post-term, but it is not a specific clinical manifestation of postterm newborns. Minimal vernix caseosa is also usually present in postterm newborns.
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Which part of the brain controls breathing?
- A. Medulla
- B. Cerebrum
- C. Cerebellum
- D. Thalamus
Correct Answer: A
Rationale: The medulla oblongata, located in the brainstem, is responsible for controlling essential autonomic functions such as breathing, heart rate, and blood pressure. Specifically, the medulla regulates the rhythm and depth of breathing by sending signals to the respiratory muscles, including the diaphragm and intercostal muscles. In response to changing levels of oxygen and carbon dioxide in the blood, the medulla adjusts the breathing rate to maintain proper oxygenation of the body tissues. Damage to the medulla can result in respiratory failure, highlighting its critical role in controlling breathing.
To help limit the development of hyperbilirubinemia in the neonate, the plan of care should include:
- A. Monitoring for the passage of meconium each shift
- B. Instituting phototherapy for 30 minutes every 6 hours
- C. Substituting breastfeeding for formula during the 2nd day after birth
- D. Supplementing breastfeeding with glucose water during the first 24 hours
Correct Answer: A
Rationale: The plan of care to help limit the development of hyperbilirubinemia in the neonate should include monitoring for the passage of meconium each shift. Meconium passage indicates proper functioning of the gastrointestinal tract and normal elimination of bilirubin, which helps prevent its build-up and subsequent development of jaundice. Monitoring for meconium passage ensures that the baby is adequately processing and excreting bilirubin, reducing the risk of hyperbilirubinemia. It is a key aspect of managing neonatal jaundice and promoting the health of the newborn.
What is an important consideration regarding TPN administration?
- A. IV site is kept aseptic while infusing the solution
- B. Feeding is poured into a pouch and then infused
- C. Solution is only hung for a maximum of 8 hours at a time New formula is added as needed so the line does not run dry
- D. Solution is only hung for a maximum of 8 hours at a time h. New formula is added as needed so the line does not run dry
Correct Answer: A
Rationale: An important consideration regarding TPN administration is ensuring the intravenous (IV) site is kept aseptic while infusing the solution. This is crucial to prevent the risk of infection, as TPN solutions are highly concentrated and can provide an ideal environment for the growth of microorganisms. Strict aseptic technique must be maintained during the entire process of TPN administration, from preparation to infusion, to minimize the risk of introducing pathogens into the patient's system. Failure to maintain aseptic technique can lead to serious complications such as bloodstream infections, which can be life-threatening for the patient.
A patient has chronic respiratory acidosis related to long-standing lung disease. Which of the following problems is the cause?
- A. Hyperventilation
- B. Loss of acid by kidneys
- C. Hypoventilation
- D. Loss of base by kidneys CARING FOR CLIENTS REQUIRING INTRAVENOUS THERAPY
Correct Answer: C
Rationale: Chronic respiratory acidosis is a condition where there is an excess of carbon dioxide (CO2) in the blood due to inadequate exhalation of CO2. This typically occurs as a result of hypoventilation, which is characterized by breathing at an abnormally slow rate or shallow depth. In patients with long-standing lung disease, the ability to effectively exchange gases in the lungs is compromised, leading to a buildup of CO2 in the bloodstream and subsequent respiratory acidosis. Hyperventilation, on the other hand, would result in a decrease in CO2 levels in the blood, while the loss of acid or base by the kidneys is related to metabolic acidosis or alkalosis, not respiratory acidosis. Therefore, in this case, the primary problem causing chronic respiratory acidosis is hypoventilation.
Under which of the ff situations should a nurse notify the physician when caring for a client with lymphangitis? Choose all that apply
- A. Affected area appears to enlarge
- B. Red streaks extend up the arm or leg
- C. Additional lymph nodes become
- D. Liver and spleen become enlarged
Correct Answer: A
Rationale: A nurse should notify the physician when caring for a client with lymphangitis under the following situations: