Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
When performing an initial assessment on a full-term infant whose parents are Asian, the nurse notes a blue-gray discoloration across the sacrum of the newborn. What is the most appropriate action for the nurse to take?
A. Review clotting studies lab report
Review clotting studies lab report: Not relevant to the assessment finding of a blue-gray discoloration.
B. Notify the healthcare provider
Notify the healthcare provider: Unnecessary unless there are other concerning clinical findings.
C. Document the findings in the electronic health record
Document the findings in the electronic health record: A blue-gray discoloration across the sacrum is likely a Mongolian spot, a benign condition more commonly seen in infants of Asian, African, Native American, and Hispanic descent. Documenting this finding in the electronic health record ensures accurate and comprehensive medical documentation without unnecessary interventions.
D. Report parents to Child Protective Services
Report parents to Child Protective Services: Inappropriate as this finding is a benign condition common among certain ethnic groups and not indicative of abuse.
This question is an excerpt from Nurse Dive's nursing test bank - Ati Nur 209 Reproductive Health Proctored Exam. Take the full exam now
Full Explanation
A. Review clotting studies lab report: Not relevant to the assessment finding of a blue-gray discoloration.
B. Notify the healthcare provider: Unnecessary unless there are other concerning clinical findings.
C. Document the findings in the electronic health record: A blue-gray discoloration across the sacrum is likely a Mongolian spot, a benign condition more commonly seen in infants of Asian, African, Native American, and Hispanic descent. Documenting this finding in the electronic health record ensures accurate and comprehensive medical documentation without unnecessary interventions.
D. Report parents to Child Protective Services: Inappropriate as this finding is a benign condition common among certain ethnic groups and not indicative of abuse.
Similar Questions
A nurse is caring for a newborn and calculating the Apgar score. At 1 min after delivery, the following findings are noted: heart rate of 110/min: slow, weak cry, some flexion of extremities; grimace in response to suctioning of the nares; body pink in color with blue extremities. Calculate the newborn's Apgar score.
Full Explanation
Heart rate (110/min): 2 points
Respiratory effort (slow, weak cry): 1 point
Muscle tone (some flexion of extremities): 1 point
Reflex irritability (grimace): 1 point
Color (body pink, blue extremities): 1 point
APGAR-6
The nurse knows which congenital cardiac defect is characterized by a mixing of well-oxygenated blood with poorly oxygenated blood.
A. Hypoplastic heart syndrome
Hypoplastic heart syndrome: Characterized by underdevelopment of the left side of the heart, not mixing of blood.
B. Atrioventricular canal defect
Atrioventricular canal defect: An atrioventricular canal defect allows oxygenated and deoxygenated blood to mix due to the presence of a common atrioventricular valve and defects in the atrial and ventricular septa. This defect results in a mixture of oxygenated and deoxygenated blood, which can cause varying levels of oxygenation in the blood delivered to the body.
C. Tetralogy of Fallot
Tetralogy of Fallot: Involves a ventricular septal defect leading to right-to-left shunting, but not a direct mixing of oxygenated and deoxygenated blood.
D. Coarctation of the aorta
Coarctation of the aorta: Involves narrowing of the aorta, not mixing of oxygenated and deoxygenated blood.
Full Explanation
A. Hypoplastic heart syndrome: Characterized by underdevelopment of the left side of the heart, not mixing of blood.
B. Atrioventricular canal defect: An atrioventricular canal defect allows oxygenated and deoxygenated blood to mix due to the presence of a common atrioventricular valve and defects in the atrial and ventricular septa. This defect results in a mixture of oxygenated and deoxygenated blood, which can cause varying levels of oxygenation in the blood delivered to the body.
C. Tetralogy of Fallot: Involves a ventricular septal defect leading to right-to-left shunting, but not a direct mixing of oxygenated and deoxygenated blood.
D. Coarctation of the aorta: Involves narrowing of the aorta, not mixing of oxygenated and deoxygenated blood.
The nurse is caring for an infant following the surgical repair of an atrial septal defect. Which nursing interventions are appropriate for this infant? (Select All that Apply.)
A. Maintain a thermoneutral environment
Maintain a thermoneutral environment: Helps prevent temperature fluctuations that can stress the heart post-surgery.
B. Accurately measure all intake and output
Accurately measure all intake and output: Ensures fluid balance is carefully monitored to prevent fluid overload or dehydration.
C. Provide for several periods of uninterrupted rest
Provide for several periods of uninterrupted rest: Reduces metabolic demand, aiding in recovery and healing.
D. Incentive spirometer 10 times every hour
Incentive spirometer 10 times every hour: Inappropriate for infants following cardiac surgery, as they are unable to effectively use an incentive spirometer.
E. Encourage periods of bonding
Encourage periods of bonding: Supports emotional well-being and aids in the infant's overall recovery and development.
Full Explanation
A. Maintain a thermoneutral environment: Helps prevent temperature fluctuations that can stress the heart post-surgery.
B. Accurately measure all intake and output: Ensures fluid balance is carefully monitored to prevent fluid overload or dehydration.
C. Provide for several periods of uninterrupted rest: Reduces metabolic demand, aiding in recovery and healing.
D. Incentive spirometer 10 times every hour: Inappropriate for infants following cardiac surgery, as they are unable to effectively use an incentive spirometer.
E. Encourage periods of bonding: Supports emotional well-being and aids in the infant's overall recovery and development.