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Which statement best describes the problem of regulation of body temperature in a 3-lb. (1361g) premature infant?
- A. The surface area of the premature infant is relatively smaller than that of a healthy-term infant.
- B. There is a lack of subcutaneous fat, which furnishes insulation.
- C. There are frequent episodes of diaphoresis causing loss of body heat.
- D. There is a limited ability to produce body proteins.
Correct Answer: B
Rationale: Lack of subcutaneous fat contributes to poor thermoregulation.
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The nurse is monitoring a client with severe preeclampsia. What assessment finding requires immediate intervention?
- A. Blood pressure of 150/90 mmHg.
- B. Urine output of 25 mL/hr.
- C. Headache relieved by acetaminophen.
- D. Deep tendon reflexes +2.
Correct Answer: B
Rationale: Oliguria (urine output <30 mL/hr) may indicate worsening renal function or severe complications in preeclampsia.
A patient is prescribed birth control pills. What should the nurse include in the patient education regarding missed doses?
- A. Take two doses the next day if you miss a dose.
- B. You should take the missed dose as soon as you remember, and take the next dose at the regular time.
- C. If you miss a dose, skip that day and continue as usual the next day.
- D. You should stop taking the pills if you miss a dose and contact your healthcare provider.
Correct Answer: B
Rationale: If a dose is missed, it should be taken as soon as remembered and the next dose taken at the usual time. Choice A is incorrect because taking two doses at once may cause side effects. Choice C is incorrect because missing a dose does not require skipping the next dose. Choice D is incorrect because missing a dose does not typically require stopping the pills, but rather following instructions to compensate for the missed dose.
Which aspect of client wellness has not been a focus of health during the 21st century ?
- A. Disease prevention
- B. Health promotion
- C. Wellness
- D. Analysis of morbidity and mortality
Correct Answer: D
Rationale: The focus on health has shifted to disease prevention, health promotion, and wellness. In the last century, much of the focus was on analyzing morbidity and mortality rates.
The nurse assigned to the care of newborn infants understands the importance of keeping these infants swaddled in a warm blanket to prevent heat loss. Why is this important in the care of the newborn?
- A. Chilling leads to increased heat production and greater oxygen needs.
- B. The newborn's metabolic rate is decreased.
- C. Evaporation will affect the newborn's ability to feed.
- D. The newborn will sleep more comfortably.
Correct Answer: A
Rationale: Preventing chilling reduces metabolic demands.
How would the nurse best analyze the results from a patient sonogram that shows the fetal shoulder is the presenting part? What position?
- A. Bridge transverse
- B. Cephalic presentation
- C. Breech presentation
- D. Vertex presentation
Correct Answer: A
Rationale: When the sonogram shows the fetal shoulder as the presenting part, it indicates a bridge transverse position. This position means that the baby is lying sideways in the uterus, with one shoulder presenting first. It is essential for the nurse to recognize this position as it may impact the mode of delivery and require additional monitoring to ensure the safe delivery of the baby. Through proper analysis and understanding of the sonogram results, healthcare providers can make informed decisions and provide appropriate care for both the mother and the baby.