Nokea
Which of the following is an abnormal finding upon
- A. To monitor hydration status physical examination of an infant?
- B. To reduce the risk of bladder injury
- C. Anterior fontanel that has a diamond-shaped open
- D. To prevent the patient from urinating during space surgery
Correct Answer: D
Rationale: The abnormal finding listed in option D, "To prevent the patient from urinating during space surgery," stands out from the rest of the options provided. This is because during space surgery, it is not necessary or appropriate to prevent the patient from urinating; rather, it is essential to focus on the surgical procedure and the patient's safety in a space environment. The other options focus on normal or abnormal physical examination findings in infants, such as the hydration status, fontanel appearance, suture line spacing, ear positioning, and uterus displacement.
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A person is admitted to the antepartum floor for hypertension. The person is Hispanic and speaks fluent English. They tell the nurse they have been seeing a curandero, or traditional healer, for the past several years. What is the best initial response from the nurse?
- A. Ask the patient for a list of all herbs, plants, and special diets they are currently taking.
- B. Educate the person on why adherence to a Western medical treatment plan is better for their health.
- C. Inform the person that the treatment they have been receiving from the curandero is not evidence based.
- D. Tell the person that they are not considering the health of their baby by using these traditions.
Correct Answer: A
Rationale: Understanding the patient's use of traditional healing practices ensures safe integration with Western medicine.
The nurse assess that a newborn is in respiratory distress when the infant exhibits:
- A. Apnea, grunting, wheezing, and crackles
- B. Wheezing, cyanosis, hiccups, and crackles
- C. Cyanosis, retraction, wheezing, and hiccups
- D. Tachypnea, retraction, grunting, and cyanosis
Correct Answer: D
Rationale: In newborns, respiratory distress can present with various signs and symptoms. The combination of tachypnea (rapid breathing), chest retractions (visible sinking of the skin in between or below the ribs with each breath), grunting (sound made during expiration), and cyanosis (blue discoloration of the skin and mucous membranes) are indicative of respiratory distress in a newborn. These signs suggest that the newborn is having difficulty breathing and may require immediate medical attention. It is essential to recognize and address respiratory distress promptly to ensure the well-being of the newborn.
A nurse is caring for a client who is 1 day postpartum and is taking a sitz bath. To determine the client's tolerance of the procedure, which of the following assessments should the nurse perform?
- A. Bladder distention
- B. Pulse rate
- C. Respiratory rate
- D. Color of lochia
Correct Answer: B
Rationale: The nurse should assess the client's pulse rate to determine the client's tolerance of the sitz bath. An elevated pulse may indicate that the sitz bath is causing discomfort or stress to the client. Monitoring the pulse rate is essential to ensure the client's safety and comfort during the procedure. Bladder distention, respiratory rate, and color of lochia are important assessments in postpartum care but are not specifically related to determining the client's tolerance of a sitz bath.
A woman's temperature has just risen 0.4°F and will remain elevated during the remainder of her cycle. She expects to menstruate in about 2 weeks. Which of the following hormones is responsible for the change?
- A. Progesterone
- B. Follicle stimulating hormone
- C. Luteinizing hormone
- D. Estrogen
Correct Answer: D
Rationale: The hormone responsible for the increase in body temperature prior to menstruation is estrogen. Estrogen is the primary female sex hormone that plays a key role in regulating the menstrual cycle. Around the time of ovulation, estrogen levels peak, which can lead to a slight rise in body temperature. This increase in temperature is known as the "estrogenic temperature shift" and is a normal part of the menstrual cycle. The rise in body temperature indicates that ovulation has occurred and that a woman is approaching her fertile window. Estrogen also helps prepare the uterine lining for pregnancy and plays a role in many other reproductive functions.
The nurse is providing education on a medical abortion. How would she describe the action of the medications?
- A. Medications thicken the lining of the uterus and decrease uterine contractions.
- B. Medications stop the fetal heart and induce contractions.
- C. Medications soften the cervix, cause uterine lining necrosis, and induce contractions.
- D. Medications thicken the cervix and the uterine lining.
Correct Answer: C
Rationale: Medications used in a medical abortion typically consist of a combination of Mifepristone and Misoprostol. The action of these medications involves three main effects: softening the cervix to facilitate the expulsion of the pregnancy tissue, causing necrosis of the uterine lining to disrupt the pregnancy, and inducing contractions to expel the contents of the uterus. This process is different from a surgical abortion, which involves a procedure to remove the pregnancy tissue from the uterus.