Nokea
Which of the following is NOT a function of hormones?
- A. Producing new offspring
- B. Promoting growth and beauty
- C. Maintaining body temperature
- D. Fighting infections
Correct Answer: A
Rationale: Hormones play various roles in the body, such as promoting growth and beauty, maintaining body temperature, and fighting infections. However, producing new offspring is not a direct function of hormones. Reproduction is primarily regulated by other factors like the reproductive system. Choice B is incorrect because hormones can indeed influence growth but not specifically 'beauty.' Choice C is incorrect as hormones can help regulate body temperature indirectly. Choice D is incorrect as hormones like cytokines can be involved in the body's immune response to fight infections.
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A postpartum client is experiencing difficulty voiding. What should the nurse include in the care plan to assist the client?
- A. Encourage the client to drink caffeine-free beverages.
- B. Apply a warm compress to the client's lower abdomen.
- C. Encourage increased fluid intake to promote urinary flow.
- D. Assist the client with Kegel exercises.
Correct Answer: B
Rationale: Applying a warm compress to the lower abdomen can help relax the muscles and stimulate voiding in postpartum clients. It promotes vasodilation, increases blood flow to the area, and can aid in relieving urinary retention. Encouraging caffeine-free beverages can also be beneficial as caffeine can irritate the bladder and worsen the situation. Increasing fluid intake helps prevent urinary stasis and promotes bladder emptying. Kegel exercises can strengthen pelvic floor muscles over time, but in the immediate situation of difficulty voiding, a warm compress is more appropriate.
An 18-month-old child presents with fever, nasal flaring, intercostal retractions, and a respiratory rate of 50 bpm. What is the most appropriate nursing diagnosis?
- A. High risk for altered body temperature - hyperthermia
- B. Ineffective breathing pattern
- C. Ineffective individual coping
- D. Knowledge deficit
Correct Answer: B
Rationale: In this case, the child is showing signs of respiratory distress, such as nasal flaring, intercostal retractions, and an increased respiratory rate. These are indicative of an ineffective breathing pattern. The child's compromised respiratory function requires immediate attention and intervention, making 'Ineffective breathing pattern' the most appropriate nursing diagnosis. Choices A, C, and D do not address the respiratory distress the child is experiencing and are not the priority in this situation.
The healthcare provider is assessing a newborn who had undergone vaginal delivery. Which of the following findings is least likely to be observed in a normal newborn?
- A. (+) Moro reflex
- B. Heart rate is 80 bpm
- C. Respirations are irregular
- D. Uneven head shape
Correct Answer: B
Rationale: A heart rate of 80 bpm is least likely to be observed in a normal newborn. The normal heart rate range for a newborn is usually higher than 80 bpm, typically ranging from 120-160 bpm. The Moro reflex (choice A) is a normal newborn reflex, respirations being irregular (choice C) are expected due to the immature respiratory control center, and an uneven head shape (choice D) is common due to molding during vaginal delivery.
A new mother asks the nurse when she should begin to breastfeed her newborn. The nurse's best response is:
- A. Within the first half-hour after birth
- B. After the newborn's first bath
- C. When the newborn begins to cry
- D. After administering vitamin K
Correct Answer: A
Rationale: Initiating breastfeeding within the first half-hour after birth is crucial for successful breastfeeding and bonding, as recommended by the World Health Organization. This early initiation helps establish breastfeeding and supports the newborn's health by providing colostrum, the nutrient-rich first milk. Choice B, 'After the newborn's first bath,' is incorrect because initiating breastfeeding should not be delayed after birth. Choice C, 'When the newborn begins to cry,' is incorrect as it does not promote timely initiation of breastfeeding. Choice D, 'After administering vitamin K,' is incorrect because breastfeeding initiation should not be delayed for this procedure.
The student nurse has performed a gestational age assessment of an infant and finds the infant to be at 32 weeks. On which set of characteristics is the nurse basing this assessment?
- A. Lanugo mostly gone, little vernix remaining on the body
- B. Prominent clitoris, enlarging labia minora, patent anus
- C. Full areola, 5 to 10 mm nipple bud, pinkish-brown areola
- D. Skin opaque, cracking at wrists and ankles, no visible vessels
Correct Answer: B
Rationale: The correct answer is B. At 30 to 32 weeks' gestation, the clitoris is prominent, and the labia minora are enlarging. The labia majora are small and widely separated. As gestational age increases, the labia majora increase in size. At 36 to 40 weeks, they almost cover the clitoris. At 40 weeks and beyond, the labia majora cover the labia minora and clitoris. Choices A, C, and D do not align with the characteristic features seen at 32 weeks of gestation, making them incorrect.