Nokea
Which of the following findings indicates the newborn is experiencing withdrawal?
- A. Bulging fontanels
- B. Acrocyanosis
- C. Bradycardia
- D. Hypertonicity
Correct Answer: D
Rationale: The correct answer is D: Hypertonicity. This finding indicates the newborn is experiencing withdrawal because it is a common symptom of withdrawal from substances such as opioids or benzodiazepines. Hypertonicity refers to increased muscle tone, which can be observed through increased resistance to passive movement. It is a sign of central nervous system hyperirritability, often seen in newborns going through withdrawal. Bulging fontanels (A) are a sign of increased intracranial pressure. Acrocyanosis (B) is a normal finding in newborns and is due to immature circulation. Bradycardia (C) is a slow heart rate, which can be caused by various factors in newborns, not specifically indicative of withdrawal.
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Which of the following findings should the nurse expect?
- A. Head circumference exceeds chest circumference
- B. Palpable fontanels
- C. Natural loss of deciduous teeth
- D. Nontender, protruding abdomen
Correct Answer: D
Rationale: The correct answer is D: Nontender, protruding abdomen. This finding is expected in a child with kwashiorkor, a form of severe protein-energy malnutrition. The nontender, protruding abdomen is due to fluid accumulation in the abdomen (ascites) and the lack of muscle mass. This is a key characteristic of kwashiorkor. The other choices are incorrect because: A) Head circumference exceeding chest circumference is not a typical finding in children; B) Fontanels should be soft and flat in infants, not palpable; C) Natural loss of deciduous teeth occurs around age 6-12 years, not in infancy.
Which of the following conflict-resolution strategies should the charge nurse use?
- A. Encourage collaboration between the two nurses when making the assignments
- B. Ask each nurse to take turns making the assignments.
- C. Tell the nurses that the assignments will be more equitable in the future.
- D. Arrange for the nurses to have as few shifts together as possible
Correct Answer: A
Rationale: The correct answer is A: Encourage collaboration between the two nurses when making the assignments. This strategy fosters open communication and teamwork, leading to a mutually agreed-upon solution. It promotes a sense of ownership and shared responsibility, enhancing job satisfaction and reducing conflict. Choice B may not address the underlying issues causing conflict. Choice C is vague and lacks a specific action plan. Choice D avoids the conflict rather than resolving it.
Which of the following statements should the nurse include in the teaching?
- A. The immunization for varicella should be given at least 1 month prior to delivery.
- B. You can receive the rubella immunization during the third trimester of pregnancy?
- C. The hepatitis& immunization should not be obtained until after you finish breastfeeding
- D. You can receive the immunization for influenza at any time during your pregnancy.
Correct Answer: D
Rationale: The correct answer is D: You can receive the immunization for influenza at any time during your pregnancy. This statement is correct because the influenza vaccine is recommended for pregnant women at any stage of pregnancy to protect both the mother and the unborn baby. It is safe and effective during pregnancy.
Incorrect choices:
A: The immunization for varicella should be given at least 1 month prior to delivery - This is incorrect because the varicella vaccine is not routinely recommended during pregnancy.
B: You can receive the rubella immunization during the third trimester of pregnancy - This is incorrect because the rubella vaccine is contraindicated during pregnancy.
C: The hepatitis B immunization should not be obtained until after you finish breastfeeding - This is incorrect because the hepatitis B vaccine is recommended during pregnancy to prevent transmission to the baby.
Which of the following Instructions should the nurse include?
- A. Remain on bed rest for 24 hours following the procedure.
- B. Participate in range-of-motion exercises.
- C. Use an incentive spirometer every 4 hours.
- D. Place a pillow under your knees while in bed.
Correct Answer: B
Rationale: The correct answer is B: Participate in range-of-motion exercises. This instruction is important to prevent complications such as blood clots and muscle stiffness post-procedure. Range-of-motion exercises help maintain joint flexibility and circulation. Choice A is incorrect as prolonged bed rest can increase the risk of blood clots. Choice C is important but not as crucial immediately post-procedure compared to mobilizing joints. Choice D is a comfort measure and does not have direct implications for post-procedure complications.
Which of the following laboratory findings should the nurse expect following the transfusion?
- A. Increased platelets
- B. Increased Hct
- C. Decreased Hgb
- D. Decreased WBC count
Correct Answer: B
Rationale: The correct answer is B: Increased Hct. Following a transfusion, the nurse should expect an increase in hematocrit (Hct) levels due to the addition of packed red blood cells. This will result in an increase in the concentration of red blood cells in the blood, leading to a higher Hct value. The other choices are incorrect as: A) Increased platelets are not typically affected by a red blood cell transfusion, C) Decreased Hgb would not be expected as the purpose of the transfusion is to increase hemoglobin levels, and D) Decreased WBC count is unrelated to a red blood cell transfusion.