Nursing Elites

1. During the initial assessment of the newborn, which of the following data would be considered normal?

• A. Chest circumference 31.5 cm, head circumference 33.5 cm
• B. Chest circumference 30 cm, head circumference 29 cm
• C. Chest circumference 38 cm, head circumference 31.5 cm
• D. Chest circumference 32.5 cm, head circumference 36 cm

Correct answer: A

Rationale: The correct answer is A. During the initial assessment of a newborn, the average head circumference at birth is 32 to 37 cm, while the average chest circumference ranges from 30 to 35 cm. Normally, the head's circumference is about 2 cm greater than the chest circumference at birth. Choice A provides measurements of chest circumference 31.5 cm and head circumference 33.5 cm, both falling within the normal range in terms of actual size and relative size. Choices B, C, and D do not align with the typical measurements seen in a healthy newborn. Choice B has both circumferences below the average range, choice C has the chest circumference above the average, and choice D has the head circumference notably higher than the chest circumference, which is not typical for a newborn.

2. Which of the following is an abnormal finding when assessing the abdomen of a newborn?

• A. The umbilical cord has two arteries and one vein.
• B. The presence of green vomit.
• C. The liver is palpable 1 to 2 cm below the costal margin.
• D. The abdomen is soft and nondistended.

Correct answer: B

Rationale: The correct answer is B. The presence of green vomit in a newborn is an abnormal finding and indicates a possible intestinal obstruction. This finding requires immediate attention and further investigation. Choices A, C, and D are normal findings in a newborn's abdomen assessment. A newborn typically has an umbilical cord with two arteries and one vein, a liver that may be palpable 1 to 2 cm below the costal margin due to its normal size in a neonate, and a soft, nondistended abdomen as expected in healthy newborns.

3. When educating the parents of a child diagnosed with hypothyroidism, the nurse mentions that the child should avoid goitrogens. Which of the following will the nurse mention as an example?

• A. Orange
• B. Tomatoes
• C. Cabbage
• D. Grapes

Correct answer: C

Rationale: Cabbage is an example of a goitrogen. Goitrogens are substances that interfere with the normal function of the thyroid gland by inhibiting iodine uptake. Cabbage, along with other cruciferous vegetables like broccoli and cauliflower, contain compounds that can have this effect and should be consumed in moderation by individuals with hypothyroidism to prevent worsening of their condition.

4. A 6-year-old child is admitted to the hospital with pneumonia. An immediate priority in this child's nursing care would be:

• A. Elimination
• B. Exercise
• C. Nutrition
• D. Rest

Correct answer: D

Rationale: Rest is crucial for recovery in a child with pneumonia as it allows the body to focus its energy on fighting the infection and promoting healing. Adequate rest helps reduce the workload on the lungs, promotes oxygenation, and supports the immune system's response to combat the infection. It is essential to prioritize rest to facilitate a faster recovery and prevent complications in children with pneumonia.

5. What is the most appropriate action to prevent heat loss in a newborn immediately after birth?

• A. Place the newborn in an incubator
• B. Bathe the newborn right away
• C. Dry the newborn thoroughly
• D. Feed the newborn

Correct answer: C

Rationale: Drying the newborn thoroughly is the most appropriate action to prevent heat loss immediately after birth. This helps to prevent heat loss through evaporation, which is crucial in maintaining the newborn's body temperature. Placing the newborn in an incubator can be a secondary step after ensuring the baby is dry. Bathing the newborn right away is not recommended as it can lead to further heat loss through evaporation. Feeding the newborn is important but not an immediate action to prevent heat loss; ensuring the baby is dry and warm takes precedence.

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