NP-2-RATIONALIZATION_81-100_ABLITER_JUSTO_GONZALES_MALABANAN_MANAIG_VARGAS.pdf

MAY 23, 2024 NP 2 RATIONALE Abliter, Joshua Malabanan, Kailla Gonzales, Elvin Manaig, Leah Janella Justo, John Miko Vargas, Loraine 81. Which observation by the nurse would assist in the diagnosis of Hirschprung's disease? A. Low grade fever B. Ab...

MAY 23, 2024 NP 2 RATIONALE Abliter, Joshua Malabanan, Kailla Gonzales, Elvin Manaig, Leah Janella Justo, John Miko Vargas, Loraine 81. Which observation by the nurse would assist in the diagnosis of Hirschprung's disease? A. Low grade fever B. Abdominal distention C. Dry, scaly skin D. Amber-colored urine 81. B. Abdominal distention Rationale: Hirschsprung disease is a condition that affects the large intestine (colon) and causes problems with passing of ribbon-like or hard caked stool that result from abdominal distention or swelling. The remaining options A, C, and D are not directly related to the diagnosis of the said disease. References: Hirschsprung's disease - Symptoms & causes - Mayo Clinic 82. The diagnosis of Hirschprung's disease is confirmed. Richard's newborn chart is reviewed. His birth weight was 3,400grams. Which note by the nurse would indicate that Richard had an early sign of a megacolon while he was in the newborn nursery? A. Day 1: Suctioned twice, Thick mucus retum B. Day 2: Passed first meconium stool C. Day 3: Axillary temperature 36 C D. Day 4: Weight 3,200 grams 82. B. Day 2: Passed first meconium stool Rationale: Meconium should be passed ideally within the first 24 hours and less frequently within the first 48 hours. There are a number of reasons why infants take longer to have their first poop, but if it is longer than 48 hours, they may need further evaluation. References: https://www.nationwidechildrens.org/family-resources- education 83. An 11-month old infant was admitted because of undernutrition and ribbon-like stools. The pediatrician gave a provisional diagnosis of Hirschsprung disease. Which of the following is the expected finding when performing a rectal exam on children with this condition? A. presence of hard caked stool B. there is leakage of watery stools C. rectum is empty D. presence of soft-formed stools 83. A. Presence of hard caked stool Rationale: Hard caked stool is a result of having a problem in the intestine. With this, when the food moves too slowly through the colon, the colon can absorb too much water from the stool. This results in hard, dry stools that can be difficult to pass. Options B, C, D are not directly related to the diagnosis of the said disease. Reference: Hard Stool: Causes, prevention, and treatment (medicalnewstoday.com) 84. The patient underwent a colostomy. Anan colostomy appliance is placed on the colostomy site. Nurse Karylle will identify what appropriate nursing diagnoses? A. Fever related to colostomy B. Impaired skin integrity related to colostomy C. Impaired urinary elimination related to decreased fluid intake D. All of the above 84. B. Impaired skin integrity related to colostomy Rationale: Fever related to colostomy will happen if there is an infection while in Impaired urinary elimination related to decreased fluid intake is not necessarily connected with the idea of colostomy. Therefore, Impaired skin integrity related to colostomy is the appropriate nursing diagnosis as stoma brings waste products through the abdominal wall, the risk for irritation to the surrounding skin is very high. Reference: https://www.hopkinsmedicine.org/health/treatment-tests- and-therapies/colostomy 85. Kim, 9 years old, is admitted because of an acute asthmatic attack. She also has cystic fibrosis. Respiratory function is altered with an asthmatic attack Which of the following is the cause of this alteration? A. Inadequate surfactant production B. Increased airway resistance C. Paradoxical movements of the chest wall D. Narrowing of the upper air passages 85. B. Increased airway resistance Rationale: Asthma is a condition characterized by airway hyperresponsiveness, which results in reversible increases in bronchial smooth muscle tone, and variable amounts of inflammation of the bronchial mucosa. During an acute asthma attack, the already inflamed airways narrow further due to bronchospasm, which leads to increased airway resistance. Reference: https://oac.med.jhmi.edu/res_phys/encyclopedia/asthma/asthma.html 86. Carla is diagnosed as having otitis media. When interpreting the documentation in Carla's electronic health record, the nurse should recognize that this diagnosis differs from otitis externa in what way? A. Otitis media occurs from swimming; otitis externa typically follows a common cold. B. Otitis media involves the middle ear: otitis externa involves the outer canal. C. Otitis media involves the eardrum; otitis externa involves the cochlear nerve D. Otitis media does not cause pain; otitis externa produces throbbing pain 86. B. Otitis media involves the middle ear; otitis externa involves outer canal Rationale: Otitis media typically follows a common cold while otitis externa occurs from swimming. Otitis externa typically involves trigeminal and facial nerve, which is responsible for sensation and movement. Lastly, Otitis media can cause pain while otitis externa produces radiating pain rather than throbbing pain. Reference: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7173526/ 87. Acute otitis media usually occurs A. because of poor hygiene B. when the child has pneumonia C. after an upper respiratory infection D. all of the above 87. C. After an upper respiratory infection Rationale: Otitis media usually occurs because of bacterial and viral infections. This type of ear infection typically follows a common cold. Reference: https://www.mayoclinic.org/diseases-conditions/ear- infections/symptoms-causes/syc-20351616 88. A newborn with a diagnosis of Imperforate anus is to be scheduled for radiographic examination. The nurse explains to the parents that this examination is done to determine the distance between the anal dimple and which of the following? A. Perineum B. Colon C. Closed end of the rectum D. Rectovesical pouch 88. C. Closed end of the rectum Rationale: Radiography often done inverted, helps determine the location of the close end of the rectum and its distance from the anal dimple. Reference:https://nurseslabs.com/imperforate-anus/#h-assessment- and-diagnostic-findings 89. Besides maintaining a patent airway, the nurse's highest priority while the neonate is in the nursery is to: A. Maintain neutral thermal environment B. Prevent infection C. Initiate first feeding D. Facilitate parent-neonate interaction 89. A. Maintain neutral thermal environment Rationale: Neonates who experience thermal stability within a TNE demonstrate enhanced growth, decreased respiratory support, decreased oxygen requirements, increased glucose stability, reduced mortality, and reduced morbidities associated with hyperthermia and hypothermia. References: https://pubmed.ncbi.nlm.nih.gov/ 90. When the nurse touches the newborn’s shoulders, the skin feels warm. The nurse knows the baby is keeping warm. A. Glucose B. Brown fat C. Glycogen D. Oxygen  90. B. Brown fat Rationale: Brown fat, also known as brown adipose tissue, is abundant in newborns and helps to keep their body temperature regulated. This specialized tissue is essential for thermoregulation in newborn. Reference: https://my.clevelandclinic.org/health/body/24015-brown-fat 91. Which of the action would be least effective in maintaining a neutral thermal environment for the newborn? A. Placing the infant under radiant warmer after bathing B. Covering the scale with warmed blanket prior to weighing C. Placing crib close to nursery window for family viewing D. Covering the infants head with knit stockings 91. C. Placing crib close to nursery window for family viewing Rationale: Heat loss by radiation happens when an infant’s crib is positioned too close to cold walls or windows. Therefore, placing the newborn’s crib near a viewing window would be the least effective method for maintaining warmth. Reference: Murray, S. S., MacKinney, E. S., Holub, K. S., Jones, R., & Scheffer, K. L. (2023). Foundations of maternal-newborn and women’s health nursing. Elsevier. 92. Vitamin K is routinely administered to newborns because A. lack of vitamin K leads to faulty blood clotting B. Vitamin K is important for digestion of milk C. Vitamin K is important for lung maturity D. Lack of vitamin K is caused by immature liver action 92. A. Lack of vitamin K leads to faulty blood clotting Rationale: Neonates and infants have low levels of vitamin K, which can lead to potentially abnormal bleeding. Given that vitamin K ensures proper blood clotting, it protects against this risk from birth. Reference: https://emedicine.medscape.com/article/974489-overview? form=fpf 93. The nurse should place two drops of silver nitrate in the eye of the baby to prevent: A. Conjunctivitis neonatorum B. Opthalmia neonatorum C. Syphilic cataract D. Congenital cataract 93. B. Ophthalmia neonatorum Rationale: Silver nitrate drops are used to prevent ophthalmia neonatorum, a particular type of conjunctivitis caused by exposure to Neisseria gonorrhoeae during birth. Reference: https://emedicine.medscape.com/article/1192190-overview 94. A newborn has vitamin K ordered IM. At which of the following sites would you expect to administer the injection? A. Gluteus maximus B. Vastus lateralis C. Ventro gluteal D. Deltoid 94. B. Vastus lateralis Rationale: The best way to give the newborn vitamin K is through an injection shortly after birth. The vastus lateralis muscle in the thigh is the ideal site for injection in newborns because of its large muscle mass and lower risk of nerve injury for potential damage. Reference: Silbert-Flagg, J., & Pillitteri, A. (2018). Maternal & child health nursing: care of the childbearing & childrearing family (Eighth edition). Wolters Kluwer. 95. Which nursing intervention helps prevent evaporative heat loss in the neonate immediately after birth? A. Administering warm oxygen B. Immediately drying the neonate C. Controlling the drafts in the room D. Placing the neonate on a warm, dry towel 95. B. Immediate drying the neonate Rationale: Drying the neonate immediately after birth removes the wetness that could lead to evaporative heat loss. This is a standard practice in neonatal care to maintain the baby's body temperature. Reference: Silbert-Flagg, J., & Pillitteri, A. (2018). Maternal & child health nursing: care of the childbearing & childrearing family (Eighth edition). Wolters Kluwer. 96. In the immediate postpartum period, you must take the woman’s vital signs: A. Every 30 minutes during the first hour and then every hour for the next two hours B. Every 15 minutes during the first hour and then every 30 minutes for the next two hours C. Every hour for the first two hour and then every four hours D. Every five minutes for the first 30 minutes and then every hour for the next 4 hours 96. B. Every 15 minutes during the first hour and then every 30 minutes for the next two hours Rationale: The initial or acute period involves the first 6-12 hours postpartum. This is a time of rapid change with a potential for immediate crises such as postpartum hemorrhage, uterine inversion, amniotic fluid embolism, and eclampsia. Reference: Silbert-Flagg, J., & Pillitteri, A. (2018). Maternal & child health nursing: care of the childbearing & childrearing family (Eighth edition). Wolters Kluwer. 97. When performing a postpartum assessment, you will note the presence of clots in the lochia. You examine the clots and notes that they are larger than 1 cm. Which of the following nursing actions is most appropriate? A. Document the findings B. Notify the physician C. Reassess the client in two hours Encourage increase oral fluid intake 97. B. Notify the physician Rationale: Normally, one may find a few small clots in the first 1 to 2 days after birth from pooling of blood in the vagina. Clots larger than 1 cm are considered abnormal. The cause of these clots, such as uterine atony or retained placental fragments, needs to be determined and treated to prevent further blood loss. Reference: Silbert-Flagg, J., & Pillitteri, A. (2018). Maternal & child health nursing: care of the childbearing & childrearing family (Eighth edition). Wolters Kluwer. 98. Which action below would lead you to believe a post-partal woman is still in the taking in phase of the post-partal period? A. She spent the majority of her day talking about labor. B. She states she is starving and cannot get enough to eat. C. She walked to take shower and wash her hair. D. She was interested in learning how to give her infant a bath. 98. A. She spent the majority of her day talking about labor Rationale: Normally, one may find a few small clots in the first 1 to 2 days after birth from pooling of blood in the vagina. Clots larger than 1 cm are considered abnormal. The cause of these clots, such as uterine atony or retained placental fragments, needs to be determined and treated to prevent further blood loss. Reference: https://nurseslabs.com/postpartum-care/#h-taking-in-phase 99. Which of the following actions would lead you to assess that a postpartal woman is entering the taking hold phase of the postpartal period? A. She sits and rocks her infant for long intervals. B. She is eager to talk about her delivery experience. C. She has not asked anything for pain today. D. She did her perineal care independently. 99. D. She did her perineal care independently Rationale: The action demonstrates increased independence and confidence especially in self-care tasks which is a common sign of the taking-hold phase. Reference: https://nurseslabs.com/postpartum-care/#h-taking-in-phase 100. When is the schedule of postpartum visit by the RHU nurse? A. 1 week postpartum B. 4 weeks postpartum C. 3 weeks postpartum D. 6 weeks postpartum 100. A. 1 week postpartum Rationale:The first postpartum visit by the RHU nurse is 3-5 days or a week; 6 weeks postpartum are recommended for the second visit. Reference: https://caro.doh.gov.ph/wp-content/uploads/2016/01/Safe- Motherhood-SA-2015-1.pdf