Nokea
Which behaviors are expected to be observed in the 18-month old?
- A. Has a vocabulary of 900 words
- B. Removes clothes
- C. Points to at least one named body part
- D. Asks many questions
- E. Can kick a ball forward
Correct Answer: B, C, E
Rationale: At 18 months, children remove clothes (B), point to body parts (C), and kick balls (E). Vocabulary is ~20-50 words (A), and questioning (D) emerges later (~2-3 years).
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A nurse is performing a vaginal exam on a client in active labor. An important landmark to assess during labor and delivery are the ischial spines because:
- A. Ischial spines are the narrowest diameter of the pelvis
- B. Ischial spines are the widest diameter of the pelvis
- C. They represent the inlet of birth canal
- D. They measure pelvic floor
Correct Answer: A
Rationale: The ischial spines mark the narrowest diameter of the pelvis, critical for assessing fetal descent during labor.
A client with B negative blood requires a blood transfusion during surgery. If no B negative blood is available, the client should be transfused with:
- A. A positive blood
- B. B positive blood
- C. O negative blood
- D. AB negative blood
Correct Answer: C
Rationale: O negative blood is the universal donor type, safe for all recipients, including B negative, as it lacks A, B, and Rh antigens, minimizing transfusion reactions.
The nurse is caring for a client with a history of a myocardial infarction who is receiving Nitroglycerin. The nurse should monitor the client for:
- A. Hypotension
- B. Tachycardia
- C. Hyperglycemia
- D. Fever
Correct Answer: A
Rationale: Nitroglycerin, a vasodilator, commonly causes hypotension due to decreased preload. Tachycardia is possible but secondary, and hyperglycemia/fever are unrelated.
A client is admitted with suspected Hodgkin's lymphoma. The diagnosis is confirmed by the:
- A. Overproliferation of immature white cells
- B. Presence of Reed-Sternberg cells
- C. Increased incidence of microcytosis
- D. Reduction in the number of platelets
Correct Answer: B
Rationale: Hodgkin's lymphoma is diagnosed by the presence of Reed-Sternberg cells in lymph node biopsy, a hallmark of the disease.
The nurse is teaching a group of prenatal clients about the effects of cigarette smoke on fetal development. Which characteristic is associated with babies born to mothers who smoked during pregnancy?
- A. Low birth weight
- B. Large for gestational age
- C. Preterm birth,but appropriate size for gestation
- D. Growth retardation in weight and length
Correct Answer: A
Rationale: Smoking during pregnancy restricts placental blood flow leading to low birth weight. Babies are not typically large and while preterm birth or growth retardation may occur low birth weight is the most consistent finding.