Nokea
While inspecting a newborn's head, the nurse identifies a swelling of the scalp that does not cross the suture line. How would the nurse refer to this finding when documenting?
- A. Molding
- B. Caput succedaneum
- C. Cephalohematoma
- D. Enlarged fontanelle
Correct Answer: C
Rationale: A cephalohematoma is caused by a collection of blood beneath the periosteum of the cranial bone. It does not cross the suture line.
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What is the nurse's best response to a mother who is voicing concern about the molding of her 2-day-old infant?
- A. Molding doesn't cause any problems. Don't worry about it.'
- B. Did you deliver vaginally or by cesarean section?'
Correct Answer: B
Rationale: Molding is a common occurrence in vaginal deliveries due to the head passing through the birth canal. Asking about the delivery method helps assess whether molding is expected and provides an opportunity to reassure the mother that it typically resolves without complications.
What information will the nurse provide when educating a woman about the correct use of a diaphragm?
- A. Use of a spermicidal cream or jelly is not recommended.
- B. Leave in place for at least 6 hours after intercourse.
- C. Remove immediately after intercourse for douching.
- D. It is effective for up to 48 hours if positioned properly.
Correct Answer: B
Rationale: To act as a barrier, the diaphragm must be left in place for at least 6 hours after intercourse and can be left in place up to, but no more than 24 hours.
What side effect would the nurse instruct a woman to look for when starting hormone replacement therapy (HRT)?
- A. Fatigue
- B. Headache
- C. Weight loss
- D. Amenorrhea
Correct Answer: B
Rationale: Patients initiating HRT are reminded to have regular follow-up care and report headaches, vision changes, symptoms of thrombophlebitis, and cardiac symptoms.
A woman is prescribed to take alendronate (Fosamax) for osteoporosis postmenopause. What information will the nurse provide when educating this patient on alendronate (Fosamax)? (Select all that apply.)
- A. Drink 8 oz. of water following dosage.
- B. Lay down for 30 minutes after taking.
- C. This medication has no known side effects.
- D. Avoid weight-bearing exercises.
Correct Answer: A
Rationale: Alendronate (Fosamax) may be prescribed. Esophageal and gastric irritation are common side effects of alendronate, and the woman should be instructed to drink 8 ounces of plain water and sit upright for 30 minutes after taking the drug and before eating a meal. Weight-bearing exercises such as walking, hiking, stair climbing, and dancing are advisable. High-impact exercises should be avoided.
The nurse reviews the procedure for breast self-examination (BSE) with a 25-year-old woman who has a family history of breast cancer. When reviewing the procedure, when will the nurse indicate as the best time for a woman to perform a breast self-examination?
- A. A few days before her period
- B. During her menstrual period
- C. On the last day of menstrual flow
- D. One week after the beginning of her period
Correct Answer: D
Rationale: The best time for BSE is 1 week after the beginning of the menstrual period.