• A woman who is 22 weeks pregnant has a vaginal infection. She tells the nurse that she is afraid that this infection will hurt the fetus. The nurse
... [Show More] knows that which of these statements is true?
A thick mucus plug forms that protects the fetus from infection.
• In assessment of 1-month-old, nurse notes a lack of response to noise or stimulation. mother reports that in the last week he has been sleeping all the time + when awake all he does is cry. nurse hears that infant’s cries are very high pitched and shrill. What would be nurse’s appropriate response?
1.Refer the infant for further testing. 2.Talk with the mother about eating habits.
3. Nothing; these are expected findings for an infant this age. 4.Tell the mother to bring the baby back in a week for a recheck.
A high-pitched shrill cry or cat-sounding screech occurs with central nervous system damage. Lethargy, hyporeactivity, hyperirritability, and parent’s report of significant change in behavior all warrant referral.
• A female patient is 8 months pregnant. She comments that she has noticed a change in posture and is having lower back pain. The nurse tells her that during pregnancy women have a posture shift to compensate for the enlarging fetus. This shift in posture is:
lordosis
• A 14-year-old girl is anxious about not having reached menarche. When taking the history, the nurse should ascertain which of the following? The age:
she began to develop breasts
• A 9-year-old girl is in the clinic for a sports physical. After some initial shyness she finally asks, “Am I normal? I don’t seem to need a bra yet, but I have some friends who do. What if I never get breasts?” The nurse’s best response would be:
“I understand that it is hard to feel different from your friends. Breasts usually develop between 8 and 10 years of age.”
• During an examination, the nurse notes a supernumerary nipple just under the patient’s left breast. The patient tells the nurse that she always thought it was a mole. Which statement about this finding is correct?
It is a normal variation and not a significant finding
• The major artery that supplies blood to arm
brachial artery
• The nurse is testing the function of cranial nerve XI. Which of these best describes the response the nurse should expect if the nerve is intact? The patient
moves head and shoulder against resistance w/equal strength
• In a person with an upper motor neuron lesion such as a cerebrovascular accident, which of the following physical assessment findings would the nurse expect to see?
1.Hyperreflexia 2.Fasciculations
3.Loss of muscle tone and flaccidity 4.Atrophy and wasting of the muscles
Hyperreflexia, diminished or absent superficial reflexes, increased muscle tone or spasticity can be expected with upper motor neuron lesions.
• A few days after a summer hiking trip, a 25-year-old man comes to the clinic with a rash. On examination, the nurse notes that the rash is red, macular, with a bull's eye pattern across his midriff and behind his knees. The nurse suspects:
Lyme Disease
• To assess the dorsalis pedis artery, the nurse would palpate
lateral to the extensor tendon of the great toe. The dorsalis pedis artery is located on the dorsum of the foot. Palpate just lateral to and parallel with the extensor tendon of the big toe. [Show Less]