Nokea
Which of the following would lead the nurse to suspect retinopathy of prematurity (ROP) when assessing a neonate at 32 weeks' gestation who weighs 2,000 g ?
- A. Sunken orbital sockets.
- B. Strabismus.
- C. Reaction to bright light.
- D. Constricted retinal vessels.
Correct Answer: D
Rationale: Constricted retinal vessels are a sign of ROP, indicating abnormal retinal vascular development.
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A 24-year-old primigravid client who delivers a viable term neonate is ordered to receive the primary effect of the placenta. Which of the following signs would indicate to the nurse that the placenta is about to be delivered?
- A. The cord lengthens outside the vagina.
- B. There is decreased vaginal bleeding.
- C. The uterus cannot be palpated.
- D. Uterus changes to discoid shape.
Correct Answer: A
Rationale: A lengthening umbilical cord outside the vagina indicates placental separation and descent, signaling imminent delivery. Decreased bleeding or a non-palpable uterus are not reliable signs, and the uterus becomes globular, not discoid, after placental delivery.
The nurse is caring for a term neonate who is diagnosed with patent ductus arteriosus. While performing a physical assessment of the neonate, the nurse anticipates that the neonate will exhibit which of the following?
- A. Decreased cardiac output with faint peripheral pulses.
- B. Profound cyanosis over most of the body.
- C. Loud cardiac murmurs through systole and diastole.
- D. Harsh systolic murmurs with a palpable thrill.
Correct Answer: C
Rationale: Patent ductus arteriosus typically causes a loud, continuous cardiac murmur heard through systole and diastole.
A nurse is teaching a client about the use of condoms for contraception. Which of the following statements by the client indicates understanding of the teaching?
- A. Condoms must be stored in a hot, humid environment.
- B. Condoms can be reused if washed thoroughly.
- C. Condoms provide some protection against STIs.
- D. Condoms are 100% effective in preventing pregnancy.
Correct Answer: C
Rationale: Condoms provide some protection against sexually transmitted infections, which is a key benefit. They should be stored in a cool, dry place, cannot be reused, and are not 100% effective in preventing pregnancy.
While assessing a neonate weighing 3,175 g (7 lb) who was born at 39 weeks' gestation to a primiparous client who admits to cocaine use during pregnancy, which of the following would alert the nurse to possible cocaine withdrawal?
- A. Bradycardia.
- B. High-pitched cry.
- C. Sluggishness.
- D. Hypocalcemia.
Correct Answer: B
Rationale: A high-pitched cry is a common sign of cocaine withdrawal in neonates, indicating neurological irritability.
A neonate delivered at 37 weeks' gestation has been admitted to the neonatal intensive care unit for respiratory distress. The physician has ordered an I.V. for fluid support. To increase safety prior to hanging new I.V. fluids for a neonate, the nurse should:
- A. Check the neonate's weight.
- B. Determine if the neonate has adequate urine output.
- C. Determine the neonate's glucose level.
- D. Double-check the fluids and physician's order with another nurse.
Correct Answer: D
Rationale: Double-checking the fluids and physician's order with another nurse ensures accuracy and safety, reducing the risk of medication or fluid errors.