Nokea
Which statement best describes the clinical manifestations of the preterm newborn?
- A. Head is proportionately small in relation to the body.
- B. Sucking reflex is absent, weak, or ineffectual.
- C. Thermostability is well established.
- D. Extremities remain in attitude of flexion.
Correct Answer: D
Rationale: The statement that best describes the clinical manifestations of the preterm newborn is that the extremities remain in an attitude of flexion. This characteristic is known as the "fetal position" and is commonly observed in preterm infants due to their premature musculoskeletal development. The flexed position of the extremities is a result of the baby's position in the uterus and is a normal finding for preterm newborns. Other clinical manifestations of preterm newborns may include a disproportionately large head in relation to the body, an immature or weak sucking reflex, and decreased thermostability due to their underdeveloped thermoregulatory systems.
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The age at which the infant achieves early head control with bobbing motion when pulled to sit is
- A. 2 mo
- B. 3 mo
- C. 4 mo
- D. 6 mo
Correct Answer: B
Rationale: Early head control with bobbing motion typically occurs around 3 months.
Which nursing intervention is appropriate for the nurse to take when setting up supplies for a client who requires a blood transfusion?
- A. Add any needed IV medication in the blood bag within one hour of planned infusion
- B. Obtain blood bag from laboratory and leave at room temperature for at least one hour prior to infusion
- C. Prime tubing of blood administration set with 0.9% NS solution, completely, filling filter
- D. Inadequate dietary intake
Correct Answer: C
Rationale: When setting up supplies for a client who requires a blood transfusion, the appropriate nursing intervention is to prime the tubing of the blood administration set with 0.9% NS solution completely, filling the filter. This is essential to ensure that the blood components flow smoothly through the tubing and any potential air bubbles are removed in order to prevent air embolism and ensure the safety of the blood transfusion process. Option A is not correct because adding IV medication in the blood bag is not a standard practice and can compromise the integrity of the blood product. Option B is also incorrect as blood products should be stored and maintained at specific temperatures to prevent spoilage or contamination; leaving it at room temperature is not advised. Option D is unrelated to setting up supplies for a blood transfusion and addresses inadequate dietary intake, which is a different nursing concern than the preparation of blood transfusion supplies.
The nursing care for the client in addisonian crisis should include which of the following interventions?
- A. Encouraging independence with activities of daily living (ADL)
- B. Allowing ambulation as tolerated
- C. Offering extra blankets and raising the heat in the room to keep the client warm
- D. Placing the client in a private room
Correct Answer: C
Rationale: The nursing care for a client in Addisonian crisis, also known as adrenal crisis, should include offering extra blankets and raising the heat in the room to keep the client warm. Addisonian crisis is a life-threatening condition that occurs when the body does not have enough cortisol and aldosterone, which are hormones produced by the adrenal glands. Symptoms of Addisonian crisis include severe weakness, fatigue, abdominal pain, nausea, vomiting, and low blood pressure. By offering extra blankets and raising the room temperature, the nurse can help prevent hypothermia, which can worsen the client's condition. It is important to maintain the client's body temperature to promote comfort and prevent further complications during Addisonian crisis.
Which of the following immunoglobulins is first produced during an acute infection?
- A. IgG
- B. IgE
- C. IgM
- D. IgD
Correct Answer: C
Rationale: IgM is the first immunoglobulin produced during an acute infection. It is the first class of antibodies secreted by B cells in response to an antigenic challenge. IgM antibodies are produced initially in primary immune responses and play a crucial role in activating the complement system. IgG is produced after IgM and is the most abundant immunoglobulin in the secondary immune response. IgE is responsible for allergic reactions, and IgD's function is not fully understood but is believed to be involved in the activation of B cells.
The nurse is preparing to administer a unit of blood to a client's who's anemic. After its removal from the refrigerator, the blood should be administered within:
- A. 1 hour
- B. 4 hours
- C. 2 hours
- D. 6 hours
Correct Answer: B
Rationale: After blood is removed from the refrigerator, it should be administered within 4 hours. Blood should be stored in a controlled temperature environment to prevent bacterial growth and to maintain its effectiveness. In order to minimize the risk of bacterial contamination, it is important for the nurse to adhere to the recommended time frame for administering blood products. Administering the blood within 4 hours helps ensure its safety and effectiveness for the client.