A nurse is obtaining the temperature of a newborn. Which of the following sites should the nurse use?
Tympanic
Oral
Axillary
Rectal
The Correct Answer is C
A. Tympanic thermometers are not recommended for newborns because the ear canal is difficult to assess accurately in this age group.
B. Oral temperatures are not recommended for newborns due to the difficulty in ensuring accuracy.
C. The axillary site is the recommended method for obtaining a newborn's temperature. It is safe and non-invasive.
D. Rectal temperatures are accurate but are invasive and may cause discomfort or injury. It should only be used if other methods are not feasible.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"A":{"answers":"B"},"B":{"answers":"B"},"C":{"answers":"A,B"},"D":{"answers":"B"},"E":{"answers":"A,B"},"F":{"answers":"A,B"}}
Explanation
|
Assessment findings |
Placenta previa |
Abruptio placenta |
|
Pain score |
✅ |
|
|
Vaginal bleeding characteristics |
✅ |
|
|
Hematocrit |
✅ |
✅ |
|
Abdominal assessment |
✅ |
|
|
Hemoglobin |
✅ |
✅ |
|
Blood pressure |
✅ |
✅ |
Rationale:
Pain: The client has abdominal pain, rated 7/10, which is sharp and associated with uterine hypertonicity and tenderness in the left upper quadrant. Placenta previa typically presents with painless bleeding and minimal to no abdominal pain, while abruptio placenta involves severe pain due to placental separation.
Vaginal bleeding: Dark red vaginal bleeding was reported. Placenta previa results in painless bright red bleeding, while abruptio placenta presents with dark red bleeding often accompanied by clots and associated pain.
Hemoglobin: Hemoglobin is 8.1 g/dL, which is low (normal range: 12 to 16 g/dL), indicating blood loss or hemorrhage. Both conditions can lead to low hematocrit and hemoglobin, but abruptio placenta may cause more significant blood loss, leading to a greater decrease in these values.
Hematocrit: The hematocrit is 24%, which is also low (normal range: 36% to 47%), further suggesting blood loss. Both conditions can lead to low hematocrit and hemoglobin, but abruptio placenta may cause more significant blood loss, leading to a greater decrease in these values.
Abdominal assessment: Placenta previa tends to show a soft abdomen with no tenderness, while abruptio placenta causes rigid, board-like abdominal muscles with tenderness, often localized.
Blood Pressure: Blood pressure is 95/62 mm Hg, which is on the lower side but not critically low. Placenta previa typically has normal or slightly low blood pressure, while abruptio placenta can cause hypotension due to significant blood loss and shock.
Fetal Heart Rate: FHR is 116/min, with minimal variability noted, which may indicate fetal distress which can be seen in both conditions.
Correct Answer is B
Explanation
A. Generativity vs. Self-absorption is the stage for adults in middle adulthood (ages 40-65), where individuals focus on contributing to society and guiding the next generation.
B. According to Erikson’s stages of psychosocial development, adolescents (ages 12-18) are in the stage of Identity vs. Role Confusion. During this stage, they work to develop a sense of personal identity and to explore different roles and beliefs.
C. Intimacy vs. Isolation occurs in young adulthood (ages 18-40), where individuals seek to form intimate relationships.
D. Trust vs. Mistrust is the first stage of Erikson’s theory, occurring during infancy (0-18 months), where infants develop a sense of trust when their needs are consistently met.
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