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Which of the following statements made by the adolescent best supports the nurse's suspicion of scoliosis?
- A. My friends are getting taller faster than I am.
- B. One of my sleeves is always shorter than the other.
- C. I have a difficult time sleeping on my side at night.
- D. I have a difficult time sleeping on my side at night.
Correct Answer: B
Rationale: Uneven sleeve length suggests shoulder asymmetry, a common sign of scoliosis due to lateral spinal curvature affecting posture.
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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.
The nurse completed discharge education to the Native American parents of a 48-hour-old,full-term infant. The nurse concludes that the mother needs additional teaching about jaundice when she makes which statement?
- A. “I know keeping my baby warm will help to decrease jaundice.”
- B. “I know the jaundice should start to decrease after about 3 days.”
- C. “The bilirubin causing the jaundice is eliminated in my baby’s stools.”
- D. “Feeding my baby frequently will help to decrease the jaundice.”
Correct Answer: B
Rationale: In Native American infants jaundice persists longer than in Caucasians with peak bilirubin at 3–5 days. Keeping warm frequent feeding and stool elimination of bilirubin are correct.
The nurse admits the term newborn,who is at risk to develop neonatal abstinence syndrome (NAS) to the newborn nursery. The nurse correctly places this infant in which location?
- A. The general nursery with 15 other infants
- B. A small,well-lit nursery with two other newborns
- C. Alone in a small,darkened nursery room
- D. Right next to the charge nurse’s desk
Correct Answer: C
Rationale: Newborns with NAS require a low-stimulus environment due to withdrawal behaviors. A small darkened room alone minimizes noise and light stimulation.
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.
The nurse is caring for a 30-year-old,single female who delivered a term newborn. What is the best way for the nurse to assess the impact of the newborn on the client’s lifestyle?
- A. Observe how the client interacts with her hospital visitors.
- B. Review the prenatal record for clues about the client’s lifestyle.
- C. Ask the client what plans she has made for newborn care at home.
- D. Observe the relationship between the client and her newborn’s father.
Correct Answer: C
Rationale: Open-ended questions about newborn care plans encourage sharing of lifestyle adjustments especially for single parents. Visitors prenatal records or father involvement are less direct.