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15 NCLEX Questions/ICP Signs and Symptoms/ Contraindicated Positions with ICP

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Five Signs and Symptoms of Increased ICP (Earliest to Latest)
1. Deteriorating level of consciousness, restlessness, irritability
2. Alteration in breathing pattern-example: Cheyne-Stokes respirations, central neurogenic hyperventilation, apnea
3 .Deterioration in motor functions abnormal posturing-example: decerebrate, decorticate, or flaccidity
4. Cushing reflex is a late sign (Severe hypertension with widening pulse pressure(Systolic and Dystolic)and bradycardia.
5. Seizure
Source: Saunders: Comprehensive Review for the NCLEX-RN Examination. Edition 5.

Three Positions Contraindicated with Increased ICP
1.Extreme neck or hip flexion/extension
2.Maintaining the head of the bed at a angle less than 30 degrees (Flat or Prone)
3.Body not midline or in neutral position (Coughing, Sneezing, Straining)

Source: ATI: Adult Surgical Nursing. Edition 8

15 NCLEX Questions: Newborn Complications

1. After resuscitation, the nurse is caring for the neonate born at 39 weeks' gestation with a diagnosis of meconium aspiration syndrome. When should the nurse expect to perform glucose testing?

Four hours of age

Eight hours of age

Two hours of age

24 hours of age

Answer: C

2. A nursing assessment of a four-hour-old neonate reveals the following data: skin cool to touch with increased movements and blood glucose level of 40 mg/mL. What should be the initial nursing action?

Increase the IV fluids.

Obtain an order for antibiotics.

Start oxygen at 4 L per minute.

Warm the newborn slowly.

Answer: D

3. A nurse is assigned to care for four newborns. The newborn most likely to develop physiologic jaundice is the one whose mother:

has diabetes.

received heparin.

has cardiac problems.

received sulfa.

Answer: D

4. A nurse is caring for a newborn receiving phototherapy. Which of the following is an appropriate nursing action?

Remove newborn from the light when drawing bilirubin levels.

Apply lotion to replace skin moisture.

Increase amount of formula to replace fluid loss.

Keep eyepatches in place at all times.

Answer: A

5. The nurse is caring for a newborn whose mother was diagnosed with group B streptococcus. Which antibiotic(s) should the nurse anticipate the physician or nurse-midwife to order for the newborn?

Ampicillin and gentamicin

Acyclovir

Nafcillin

Vancomycin

Answer: A

6. A neonate has an apical heart rate of 48 beats per minute after 30 minutes of cardiac compression. Which medication would the nurse anticipate giving?

Narcan (naloxone)

Intropin (dopamine)

Apresoline (hydralazine)

Epinephrine

Answer: D

7. A nurse is administering epinephrine to a compromised newborn. What is the most accessible vein for administering this medication?

Femoral vein

Brachial vein

Scalp vein

Umbilical vein

Answer: D

8. A nurse is assisting with the birth of a compromised newborn who is making spontaneous respiratory efforts. What should be the initial nursing action?

Place the newborn under a radiant heat warmer.

Suction the oral and nasal passages.

Stimulate the newborn by rubbing the feet.

Perform cardiac and respiratory resuscitation.

Answer: B

http://wps.prenhall.com/chet_olds_maternal_7/11/2965/759277.cw/index.html

9. A nurse is caring for a small-for-gestational-age (SGA) neonate. What complication is this baby at risk for?

Polycythemia

Hyperglycemia

Seizures

Hyperviscosity

Answer: A

10. A nurse is caring for a two-hour-old infant of a diabetic mother. How frequently should the nurse monitor the infant's blood glucose level?

Every hour

Every two hours

Every four hours

Once a shift

Answer: A

11. A nurse is caring for an infant who was exposed to alcohol in utero. What characteristic(s) might this baby exhibit?

Rhinorrhea and genital candidiasis

Cyanosis

Hypertonicity and jitteriness

Microcephaly and facial abnormalities

Answer: D

12. A 32-week-gestation neonate in the neonatal intensive care unit is being fed intravenously. How often should the nurse change the IV solutions and tubing?

Every feeding.

Every eight hours.

Every shift.

Every 24 hours.

Answer: D

13. A nurse is caring for a 37-week-gestation neonate who frequently sneezes, hiccups and yawns, has poor feeding and diarrhea, has mild tremors when stimulated, and with respirations of 70 breaths per minute when quiet. These clinical manifestations are typical of which condition? [

None

Newborn Withdrawal or neonatal abstinence syndrome

Fetal Alcohol Syndrome (FAS)

Infant of a Diabetic Mother (IDM)

Answer: B

14. An HIV positive mother asks the nurse, "How soon can I know if my baby has HIV?" What is the correct response by the nurse?

"We should know within 24 hours after birth using the PCR test."

"It takes about six months before your baby will develop symptoms."

"At birth, we will take a sample of the umbilical cord blood to test for the virus."

"Current serologic tests cannot differentiate between your blood and your baby's blood for 15 months."

Answer: A

15. A nurse is teaching new parents about the recommended genetic screening tests available for babies prior to discharge. These screening programs test for disorders associated with which of the following?

Mental retardation

Cardiac anomalies

Neural tube defects

Congenital anomalies

Answer: A

http://wps.prenhall.com/chet_olds_maternal_7/11/2965/759237.cw/index.html


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