Nokea
Which nursing interventions should be included in the care plan of a child in skeletal traction? Select all that apply.
- A. Maintain the child in the prone position.
- B. Clean the pin site every 8 hours.
- C. Release weights on the traction every 2 hours.
- D. Monitor client for signs of cloudy urine.
- E. Cover protruding tips of pins with protective materials.
Correct Answer: B,D,E
Rationale: Cleaning pin sites every 8 hours prevents infection, monitoring for cloudy urine detects urinary tract infections due to immobility, and covering pin tips ensures safety. Prone position is not standard, and weights should not be released.
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The common possible cause of oligohydramnios is:
- A. Oesophageal atresia.
- B. Placental haemangioma.
- C. Renal agenesis.
- D. Diabetes mellitus.
- E. Rh incompatibility.
Correct Answer: C
Rationale: Renal agenesis leads to oligohydramnios because the fetus cannot produce urine a major component of amniotic fluid. Other options are less commonly associated with reduced amniotic fluid.
Calculating from the date of the mother’s last menstrual period,the nurse determines that her newborn’s gestational age is 40 weeks. Which normal findings should the nurse expect when assessing this newborn at birth? Select all that apply.
- A. Hypertonic flexion of all extremities.
- B. Sole creases on the anterior two-thirds of the sole.
- C. Well-defined incurving of the entire ear pinna.
- D. Presence of a prominent clitoris.
- E. Infant is able to support the head momentarily when pulled to a sitting position.
Correct Answer: A,C,E
Rationale: Full-term newborns (40 weeks) exhibit hypertonic flexion well-defined ear pinna incurving and momentary head support. Sole creases over two-thirds indicate ~37 weeks and a prominent clitoris is seen at 30–32 weeks.
The nurse is caring for the newborn infant. The nurse should prepare to assess the newborn’s anterior fontanel by which method?
- A. Lay the infant on his or her back.
- B. Stimulate the infant to cry strongly.
- C. Feel near the parietal and occipital bones.
- D. Place the infant in a sitting position.
Correct Answer: D
Rationale: The anterior fontanel is assessed with the infant in a sitting position (45°–90°) to evaluate size and abnormalities. Supine positioning or crying may cause bulging and parietal/occipital bones locate the posterior fontanel.
Which symptom reported by the parents is best indicative of methamphetamine abuse by the adolescent?
- A. Watery eyes
- B. Drowsiness
- C. Excessive nasal drainage
- D. Marked nervousness
Correct Answer: D
Rationale: Methamphetamine, a stimulant, causes marked nervousness due to increased central nervous system activity, making it a key indicator of abuse.
A 30 years old G5P4 is admitted in labor room with H/O 32 weeks gestation,mild vaginal bleeding and abdominal pain. O/E her blood pressure 140/100 mm Hg abdomen is tense tender and hard. Fetal heart sounds are not audible. What is the most likely diagnosis:
- A. Placenta praevia.
- B. Abruptio placenta.
- C. Preterm labour.
- D. Urinary tract infection.
- E. Vasa praevia.
Correct Answer: B
Rationale: Abruptio placenta presents with vaginal bleeding abdominal pain a tense uterus and fetal distress (absent heart sounds) often with hypertension. Placenta previa typically causes painless bleeding and other options do not match the clinical picture.