Nokea
Which of the following vaccines is not part of the regular schedule of immunizations for children?
- A. DTaP
- B. MMR
- C. Hib
- D. hepatitis A
Correct Answer: D
Rationale: The correct answer is hepatitis A. DTaP, MMR, and Hib are all part of the regular schedule of immunizations for children to protect them against diseases like diphtheria, tetanus, pertussis, measles, mumps, rubella, and Haemophilus influenzae type b. Hepatitis A vaccine is not included in the routine childhood immunization schedule but may be recommended in certain situations or regions where the disease is more prevalent. Hepatitis A is generally considered an optional vaccine for children but can be administered based on specific risk factors or regional guidelines.
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When planning for the physical assessment of the woman, the nurse ensures that which occurs?
- A. The woman is examined by a female health care provider.
- B. The woman's husband remains in the examining room at all times.
- C. The woman is examined without any other people in the examining room.
- D. Written permission is obtained from the woman to obtain subjective health data.
Correct Answer: A
Rationale: In many cultures, including Muslim, Hindu, and Latino, modesty is important, and exposure of a woman's genitals to men is considered demeaning. To respect the patient's cultural beliefs and modesty, it is best for a female health care provider to perform the examination. This practice helps to ensure the patient's comfort and adherence to cultural norms. Having the woman examined without any other people in the room (Choice C) may not address the cultural sensitivity required for this situation. Having the woman's husband remain in the examining room at all times (Choice B) may not align with the patient's cultural preferences and may cause discomfort. Written permission from the woman to obtain subjective health data (Choice D) is not directly related to ensuring a culturally sensitive physical assessment in this context.
A nurse calculates a newborn infant's Apgar score 1 minute after birth and determines that the score is 6. What is the most appropriate action for the nurse to take?
- A. Initiate cardiopulmonary resuscitation
- B. Gently stimulate the infant by rubbing his back while administering oxygen
- C. Recheck the score in 5 minutes
- D. Provide no action except to support the infant's spontaneous efforts
Correct Answer: B
Rationale: The Apgar score is a method for rapidly evaluating an infant's cardiorespiratory adaptation after birth. The nurse assigns scores in five areas: heart rate, respiratory effort, muscle tone, reflex response, and color, totaling the scores. A score of 8 to 10 requires no action other than supporting the infant's spontaneous efforts and observation. A score of 4 to 7 indicates the need to gently stimulate the infant by rubbing his back while administering oxygen. If the score is 1 to 3, the infant requires resuscitation. Therefore, in this scenario with an Apgar score of 6, the correct action is to gently stimulate the infant by rubbing his back while administering oxygen. Initiating cardiopulmonary resuscitation would be excessive at this point, and rechecking the score in 5 minutes may delay necessary interventions. Providing no action except to support the infant's spontaneous efforts is insufficient for a score of 6, indicating the need for stimulation and oxygen administration.
A nurse in the newborn nursery, assisting with data collection for a newborn, prepares to measure the chest circumference. The nurse places the tape measure around the infant at which location?
- A. In the axillary area
- B. At the level of the nipples
- C. Two inches below the nipples
- D. At the level of the umbilicus
Correct Answer: B
Rationale: The chest circumference of the infant is measured at the level of the nipples. It is usually 2 to 3 cm smaller than the head circumference. The average chest circumference is 30.5 to 33 cm (12-13 inches). When there is molding of the head, the head and chest measurements may be equal at birth. Placing the tape measure at the level of the nipples ensures accuracy and consistency in newborn assessment. Options A, C, and D are incorrect as the chest circumference is specifically measured at the level of the nipples to obtain precise measurements.
A multigravida pregnant woman asks the nurse when she will start to feel fetal movements. Around which week of gestation does the nurse tell the mother that fetal movements are first noticed?
- A. 16 weeks
- B. 6 weeks
- C. 8 weeks
- D. 12 weeks
Correct Answer: A
Rationale: Fetal movements (quickening) are first noticed by multigravida pregnant women at 16 to 20 weeks of gestation and gradually increase in frequency and strength. This is when the mother typically begins to feel the baby's movements. Choices B, C, and D are incorrect because fetal movements are not felt as early as 6, 8, or 12 weeks of gestation. At 6 weeks, the embryo's movements are not yet strong enough to be felt by the mother. By 8 weeks, the movements are still too subtle to be perceived. At 12 weeks, although fetal movements start, they are usually not strong enough to be felt by the mother.
An amniocentesis is scheduled for a pregnant client in the third trimester. The nurse informs the client that the most common indication for amniocentesis during the third trimester is for which reason?
- A. Determination of whether alpha-fetoprotein (AFP) is present in the amniotic fluid
- B. Checking the amniotic fluid for intrauterine infection
- C. Determination of fetal lung maturity
- D. Checking the fetal cells for chromosomal abnormalities
Correct Answer: C
Rationale: The most common indication for amniocentesis in the third trimester is the determination of fetal lung maturity. This assessment is essential to evaluate the fetus's readiness for extrauterine life. Checking for alpha-fetoprotein (AFP) in the amniotic fluid is more commonly associated with midtrimester amniocentesis to identify chromosomal abnormalities. Assessing for intrauterine infection is not a primary reason for amniocentesis in the third trimester. While checking fetal cells for chromosomal abnormalities is a common indication for midtrimester amniocentesis, it is not the most common indication in the third trimester.