Nokea
Which of the following would the nurse expect to assess in a neonate delivered at 28 weeks' gestation who is diagnosed with intraventricular hemorrhage (IVH)?
- A. Increased muscle tone.
- B. Hyperbilirubinemia.
- C. Bulging fontanels.
- D. Hyperactivity.
Correct Answer: C
Rationale: Bulging fontanels are a sign of increased intracranial pressure from IVH in preterm neonates.
You may also like to solve these questions
The physician orders an intramuscular injection of phytonadione (AquaMEPHYTON) for a term neonate. The nurse explains to the mother that this medication is used to prevent which of the following?
- A. Hypoglycemia.
- B. Hyperbilirubinemia.
- C. Hemorrhage.
- D. Polycythemia.
Correct Answer: C
Rationale: Phytonadione (vitamin K) is administered to newborns to prevent hemorrhagic disease due to low vitamin K levels, which are necessary for blood clotting.
After suction and evacuation of a complete hydatidiform mole, the 28-year-old multigravid client asks the nurse when she can become pregnant again. The nurse would advise the client not to become pregnant again for at least which of the following time spans?
- A. 6 months.
- B. 12 months.
- C. 18 months.
- D. 24 months.
Correct Answer: B
Rationale: Waiting 12 months allows for monitoring for choriocarcinoma.
A client is considering the contraceptive patch. Which of the following instructions should the nurse provide?
- A. Apply a new patch daily for three weeks, then skip a week.
- B. Change the patch weekly for three weeks, then have a patch-free week.
- C. Wear the patch for one month, then replace it.
- D. Apply the patch to the genital area for best results.
Correct Answer: B
Rationale: The contraceptive patch is changed weekly for three weeks, followed by a patch-free week to allow for a withdrawal bleed. It is not applied daily, worn for a month, or placed on the genital area.
The nurse is managing care of a primigravida at full term who is in active labor. What should be included in developing the plan of care for this client?
- A. Oxygen saturation monitoring every half hour.
- B. Supine positioning on back, if it is comfortable.
- C. Anesthesia/pain level assessment every 30 minutes.
- D. Vaginal bleeding, ROM assessment every shift.
Correct Answer: C
Rationale: Regular assessment of anesthesia/pain levels is critical to ensure the client's comfort and to adjust pain management strategies as labor progresses. Oxygen saturation monitoring is not typically required every half hour unless specific complications arise. Supine positioning can cause supine hypotensive syndrome and is generally avoided. Vaginal bleeding and rupture of membranes (ROM) assessments are important but typically performed more frequently than every shift during active labor.
While caring for a male neonate diagnosed with gastroschisis, the nurse observes that the parents seem hesitant to touch the neonate because of his appearance. The nurse determines the presence of which of the following stages of grief?
- A. Denial.
- B. Shock.
- C. Bargaining.
- D. Anger.
Correct Answer: B
Rationale: The parents' hesitation to touch the neonate suggests shock, as they are likely overwhelmed by the neonate's condition.