The nurse notes that when a neonate is stroked on the left cheek, he turns his head toward the left. The nurse is assessing a(n):
a. normal reflex called the tonic neck reflex.
b. abnormal response that needs to be further evaluated.
c. abnormal response known as head turning.
d. normal reflex called the rooting reflex.
ANS: D
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Which symptom in an infant may indicate a possible food allergy?
a. Taking small amounts at feedings b. Stuffy nose and breathing difficulties c. Spitting up after a feeding d. Constipation
A patient being seen for an elevated, darkened area of excess scar tissue asks the nurse what caused it. How should the nurse respond?
1. "This scar was caused by the wearing away of the superficial epidermis, which left a moist, shallow depression." 2. "This scar was caused by excessive collagen formation during healing." 3. "This scar was caused by skin loss extending into the dermis or subcutaneous tissue." 4. "This scar was caused by wasting of the skin due to loss of collagen."
A nurse manager has recently held an educational program for newly hired nurses on the high acuity care unit. Which of the statements by a participant indicates the need for further education?
1. "The plan of care should ensure the wishes of the patient at the time of death.". 2. "The palliative care plan should seek to ensure the patient and family understands the disease status.". 3. "Advanced directives are not included in the palliative plan of care.". 4. "The goals of medical care should be included in the palliative plan of care.".
A nurse assessing a newborn knows that the most critical physiologic change required of the newborn is:
1. closure of fetal shunts in the circulatory system. 2. full function of the immune defense system at birth. 3. maintenance of a stable temperature. 4. initiation and maintenance of respirations.