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During the admission procedure of a 6-year-old, the child states, 'I'm going to have an operation.' Which response is best for the nurse to provide to this child?
- A. Are you scared?
- B. We're going to do everything we can to take very good care of you.
- C. Tell me what an operation is.
- D. I'm glad your mother told you why you were coming to the hospital.
Correct Answer: B
Rationale: In this situation, the most appropriate response for the nurse is to provide reassurance and express care to alleviate the child's anxiety about the upcoming operation. By reassuring the child that everything will be done to take very good care of them, the nurse helps build trust and comfort, creating a positive and supportive environment for the child.
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A client who gave birth to a healthy 8-pound infant 3 hours ago is admitted to the postpartum unit. Which nursing plan is best in assisting this mother to bond with her newborn infant?
- A. Encourage the mother to provide total care for her infant.
- B. Provide privacy so the mother can develop a relationship with the infant.
- C. Encourage the father to provide most of the infant's care during hospitalization.
- D. Meet the mother's physical needs and demonstrate warmth toward the infant.
Correct Answer: D
Rationale: Meeting the mother's physical needs and demonstrating warmth toward the infant is essential in creating a supportive environment that fosters bonding between the mother and the newborn. By ensuring the mother's comfort and well-being, the nurse can help promote a positive interaction between the mother and her infant, leading to a stronger emotional connection and bonding.
A neonate with congenital adrenal hypoplasia (CAH) presents with ambiguous genitalia. What is the primary nursing consideration when supporting the parents of a child with this anomaly?
- A. Discuss the need for cortisol and aldosterone replacement therapy after discharge
- B. Support the parents in their decision regarding the sex assignment of their child
- C. Offer information about ultrasonography and genotyping to determine sex assignment
- D. Explain that corrective surgical procedures consistent with sex assignment can be delayed
Correct Answer: B
Rationale: Supporting the parents in their decision regarding the sex assignment of their child is crucial as it respects the parental role in making this important decision and helps provide emotional support during a challenging time. The primary focus should be on helping the parents navigate the complexities and implications of determining the sex assignment for their child with ambiguous genitalia.
While caring for a laboring client on continuous fetal monitoring, the nurse notes a fetal heart rate pattern that falls and rises abruptly with a 'V' shaped appearance. What action should the nurse take first?
- A. Change the maternal position.
- B. Administer oxygen at 10 L by mask.
- C. Prepare for a potential cesarean.
- D. Allow the client to begin pushing.
Correct Answer: A
Rationale: In cases of fetal heart rate patterns showing abrupt falls and rises with a 'V' shaped appearance, it indicates possible cord compression. Changing the maternal position, such as moving the mother onto her side, can relieve the pressure off the cord and help improve fetal oxygenation, making it the priority intervention to address the decelerations.
In developing a teaching plan for expectant parents, the nurse plans to include information about when the parents can expect the infant's fontanels to close. The LPN/LVN bases the explanation on knowledge that for the normal newborn, the
- A. anterior fontanel closes at 2 to 4 months and the posterior by the end of the first week.
- B. anterior fontanel closes at 5 to 7 months and the posterior by the end of the second week.
- C. anterior fontanel closes at 8 to 11 months and the posterior by the end of the first month.
- D. anterior fontanel closes at 12 to 18 months and the posterior by the end of the second month.
Correct Answer: D
Rationale: The anterior fontanel typically closes between 12 to 18 months, while the posterior fontanel usually closes by the end of the second month. It is important for parents to know these timeframes as it helps in monitoring the normal growth and development of their newborn. Delayed closure of fontanels may indicate potential health issues, and early closure may also warrant further evaluation by healthcare providers.
A laboring client's membranes rupture spontaneously. The nurse notices that the amniotic fluid is greenish-brown. What intervention should the nurse implement first?
- A. Turn the client to her left side
- B. Contact the healthcare provider
- C. Assess the fetal heart rate
- D. Check the cervical dilation
Correct Answer: C
Rationale: The correct answer is to assess the fetal heart rate. When amniotic fluid is greenish-brown, it may indicate the presence of meconium, which can be concerning as it may lead to fetal distress. Assessing the fetal heart rate will help determine the well-being of the fetus and guide further actions to ensure the safety of both the mother and the baby.