Nokea
Which of the following nursing diagnoses would be inappropriate for the infant with gastroesophageal reflux (GER)?
- A. Fluid volume deficit
- B. Risk for aspiration
- C. Altered nutrition: less than body requirements
- D. Altered oral mucous membranes
Correct Answer: D
Rationale: GER is the backflow of gastric contents into the esophagus resulting from relaxation or incompetence of the lower esophageal (cardiac) sphincter. No alteration in the oral mucous membranes occurs with this disorder.
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What complication can result from untreated respiratory distress in the newborn?
- A. Esophageal atresia
- B. Gastric dilation
- C. Cold stress
- D. Reopening of the foramen ovale
Correct Answer: D
Rationale: Respiratory distress can cause increased pressure in the right ventricle, causing reopening of the foramen ovale.
A child with iron deficiency anemia is prescribed oral iron supplements. What should the nurse instruct the parents regarding administration?
- A. Administer the iron with milk for better absorption
- B. Expect stools to be tarry and black
- C. Give the iron supplement through a straw to avoid staining teeth
- D. Iron supplements are best absorbed when taken with food
Correct Answer: C
Rationale: Using a straw minimizes tooth staining from liquid iron, a common side effect. Iron is best absorbed on an empty stomach, and milk reduces absorption; tarry stools are expected but not the focus of administration instruction.
Which hormone initiates the maturation of the ovarian follicle?
- A. Estrogen
- B. Follicle-stimulating hormone
- C. Progesterone
- D. Luteinizing hormone
Correct Answer: B
Rationale: Follicle-stimulating hormone (FSH) stimulates the maturation of a follicle.
You’re assessing the one minute APGAR score of a newborn baby. On assessment, you note the following about your newborn patient: heart rate 101, cyanotic body and extremities, no response to stimulation, no flexion of extremities, and strong cry. What is your patient’s APGAR score?
- A. APGAR 4
- B. APGAR 6
- C. APGAR 3
- D. APGAR 2
Correct Answer: A
Rationale: APGAR scoring: Heart rate 101 (2 points), cyanotic body/extremities (0 points), no response to stimulation (0 points), no flexion (0 points), strong cry (2 points). Total = 2 + 0 + 0 + 0 + 2 = 4.
The normal volume of amniotic fluid is approximately __ $\mathrm{mL}$ at 37 weeks gestation.
- A. 500
- B. 750
- C. 1000
- D. 1250
Correct Answer: C
Rationale: The volume of amniotic fluid steadily increases from about $30 \mathrm{~mL}$ at 10 weeks of pregnancy to $350 \mathrm{~mL}$ at 20 weeks. The volume of fluid is about $1000 \mathrm{~mL}$ at 37 weeks.