Which of the following clients would the nurse report as a suspected abuse case?

A 10-year-old with a burn on the palm of the hand

A 6-year-old with splash burns on the front torso

A 4-year-old with circular abrasions around the wrists

A 2-year-old with a large bruise on the forehead

Answer and Explanation

The Correct Answer is C

A. A 10-year-old with a burn on the palm of the hand: This could potentially be accidental, for example, from touching a hot surface. However, while it requires further investigation, it is not as strongly indicative of abuse as the given option.
B. A 6-year-old with splash burns on the front torso: These burns could result from accidentally spilling hot liquids. Though it raises concern, it often indicates an accident rather than abuse unless accompanied by other suspicious signs.
C. A 4-year-old with circular abrasions around the wrists: This is highly suspicious of abuse because circular abrasions can indicate that the child may have been tied or restrained, which is not typical of accidents or normal play.
D. A 2-year-old with a large bruise on the forehead: This type of injury is common in young children who are prone to falls and bumps. It might not immediately suggest abuse without additional context.

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Correct Answer is B

Explanation

A. O negative blood type. This is significant for Rh incompatibility if the fetus is Rh-positive, but it is managed through routine prenatal care and does not require immediate intervention at 36 weeks.
B. Blood pressure 144/94 mmHg in left arm. This finding is concerning because it may indicate the development of preeclampsia, which requires immediate medical attention due to the potential risks to both the mother and fetus.
C. Positive rubella serum antibody titer. A positive titer indicates immunity to rubella, which is a good finding in pregnancy and not a concern.
D. Copious leukorrhea. This is common in late pregnancy and typically not a cause for concern unless it is accompanied by signs of infection or rupture of membranes.

A. Wash the cord daily with mild soap and water. B. Cover the cord with the diaper. C. Apply petroleum jelly to the cord stump. D. Give a sponge bath until the cord stump falls off.

Correct Answer is D

Explanation

A. Wash the cord daily with mild soap and water. Incorrect because keeping the area dry is crucial; soap can irritate the area.
B. Cover the cord with the diaper. Incorrect because it may trap moisture and cause irritation or infection.
C. Apply petroleum jelly to the cord stump. Incorrect because this may keep the area too moist and prevent it from drying and falling off naturally.
D. Give a sponge bath until the cord stump falls off. This prevents the cord from getting wet, which can increase the risk of infection and delay drying and detachment.

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Which of the following clients would the nurse report as a suspected abuse case?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse identifies the following assessment findings in a client who is 36 weeks' gestation. Which should be immediately reported to the provider?

Correct Answer is B

Explanation

A nurse is teaching a newborn's parent to care for the umbilical cord stump. Which of the following instructions should the nurse include?

Correct Answer is D

Explanation

When teaching a menopausal woman who chooses not to use hormone therapy what self-care measure is most important to include?

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