The nurse is performing a general survey of a patient. Which finding is considered normal?

Correct Answer: D

Rationale: The correct answer is D because arm span equaling the patient's height is considered normal. This is known as the ape index, where arm span is equal to height. This finding indicates proportional body development. A is incorrect as a narrow base when standing is abnormal. B is incorrect as appearing older than stated age is abnormal. C is incorrect as arm span greater than height can indicate abnormal growth or a medical condition.

Correct Answer: D

Rationale: The correct answer is D: Trichotillomania; her child probably has a habit of absentmindedly twirling her hair. Trichotillomania is a psychological disorder characterized by the urge to pull out one's hair. In this case, the irregularly shaped patches with broken-off, stublike hair suggest hair pulling rather than a medical condition like folliculitis (A), traumatic alopecia (B), or tinea capitis (C). Folliculitis is a bacterial infection of hair follicles, not related to hair pulling. Traumatic alopecia is hair loss due to physical damage, not consistent with the described symptoms. Tinea capitis is a fungal infection causing hair loss and is not typically associated with broken-off, stublike hair. Trichotillomania is the most likely explanation given the presentation of the child's hair condition.

Correct Answer: B

Rationale: The correct answer is B: Rubella can damage the infant's organ of Corti, which will impair hearing. Rubella virus can cross the placenta and infect the developing fetus, leading to congenital rubella syndrome. This syndrome can cause damage to various organs including the organ of Corti in the inner ear, leading to hearing impairment. This occurs mainly when the infection happens during the first trimester when the organ systems are developing. Incorrect choices: A: Rubella may affect the mother's hearing but not the infant's - This is incorrect as rubella can indeed affect the infant's hearing through congenital rubella syndrome. C: Rubella is only dangerous to the infant in the second trimester of pregnancy - This is incorrect as rubella can harm the infant's hearing in the first trimester as well. D: Rubella can impair the development of CN VIII and thus affect hearing - While rubella can affect hearing, it primarily does so by damaging the organ of Corti

Correct Answer: B

Rationale: The correct answer is B: Hypomobility. In otitis media, there is an accumulation of fluid in the middle ear, which can lead to decreased mobility of the tympanic membrane. This can be observed during pneumatic otoscopy when the tympanic membrane does not move normally in response to insufflation. Choices A, C, and D are incorrect. A) A red and bulging tympanic membrane is more indicative of acute otitis media. C) Retraction with landmarks clearly visible is a sign of negative pressure in the middle ear, possibly indicating eustachian tube dysfunction. D) A flat, slightly pulled in at the center, and moves with insufflation is characteristic of a normal tympanic membrane.

Correct Answer: B

Rationale: The correct answer is B: Recognize that this situation requires immediate intervention. If the nurse is unable to suction the nares and pass a catheter through, it suggests a potential blockage or obstruction in the nasal passages, which could lead to respiratory distress. Immediate intervention is crucial to ensure the newborn's airway is clear and breathing is not compromised. Contacting the physician or seeking further medical assistance promptly is necessary to address the issue. Choice A is incorrect because simply attempting to suction again may not resolve the underlying obstruction, and delaying necessary intervention could be harmful. Choice C is incorrect as scheduling an appointment for the infant at a later time is not appropriate when immediate intervention is required. Choice D is not applicable as it does not provide any solution or guidance for the current situation.