Nokea
Immediately after birth, the nurse places the newborn under a radiant warmer. Which is the primary rationale for the nurse's action?
- A. To facilitate an efficient means of thermoregulation
- B. To facilitate initial assessment by the nurse
- C. To permit the use of the cardiac monitor
- D. To permit close observation by the family members
Correct Answer: A
Rationale: The correct answer is A: To facilitate an efficient means of thermoregulation. Placing the newborn under a radiant warmer helps prevent hypothermia by maintaining the baby's body temperature. Newborns have difficulty regulating their own body temperature initially, so the radiant warmer provides a controlled environment to keep them warm. Choice B is incorrect because the primary reason is not for assessment but for thermoregulation. Choice C is incorrect as a cardiac monitor is not typically needed immediately after birth. Choice D is incorrect as the primary focus is on the newborn's well-being, not family observation.
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A nurse is performing a routine physical examination on an adolescent client who asks, 'Why do I have to use a condom if my girlfriend is on the pill?' Which of the following is the most appropriate response by the nurse?
- A. You need to use two forms of birth control so if one fails you have a second form of protection against pregnancy.
- B. Using a condom allows you to share the responsibility for birth control.
- C. Oral contraceptives are less than 99 percent effective in adolescents. Therefore, a second form of contraception is needed.
- D. Oral contraceptives are highly effective in preventing pregnancy but do not prevent sexually transmitted diseases.
Correct Answer: D
Rationale: The correct answer is D. The nurse should explain that while oral contraceptives are highly effective in preventing pregnancy, they do not protect against sexually transmitted diseases (STDs). This is important because even if the girlfriend is on the pill, using a condom is necessary to prevent STD transmission. Adolescents are at higher risk for STDs, so it is crucial to emphasize the importance of dual protection. Choice A is incorrect as it does not specifically address the risk of STD transmission. Choice B is incorrect because it focuses on shared responsibility rather than the health implications of using a condom. Choice C is incorrect as it emphasizes the effectiveness of oral contraceptives rather than the need for STD protection.
A client reports awaking from sleep by contractions that are occurring every five minutes and lasting 30-40 seconds. Which of the following questions should the nurse ask to assess for true labor versus false labor?
- A. When did your contractions begin?
- B. Have you noticed any bloody show or fluid coming from your vagina?
- C. What happens to your contractions when you move about?
- D. Have you felt fetal movement over the last 24 hours?
Correct Answer: B
Rationale: The correct answer is B: "Have you noticed any bloody show or fluid coming from your vagina?" This question helps differentiate true labor from false labor because the presence of bloody show or amniotic fluid suggests cervical changes associated with true labor. Bloody show indicates the shedding of the cervical mucus plug, and amniotic fluid leakage indicates rupture of membranes. This information helps confirm the progression of labor.
Choice A: "When did your contractions begin?" is a general question that does not specifically differentiate between true and false labor.
Choice C: "What happens to your contractions when you move about?" is more related to the management of labor rather than differentiating true labor from false labor.
Choice D: "Have you felt fetal movement over the last 24 hours?" is important for assessing fetal well-being but does not help in distinguishing true labor from false labor.
A nurse is checking children at an orthopedic outpatient setting. Which of the following should the nurse expect to see as manifestations of scoliosis?
- A. Pain and an exaggerated lumbar curvature'
- B. Uneven shoulder heights and poorly fitting slacks'
- C. Tenderness and swelling of the spine'
- D. Limited range of motion of the back and a limp'
Correct Answer: B
Rationale: The correct answer is B. Uneven shoulder heights and poorly fitting slacks are common manifestations of scoliosis because the condition causes an abnormal curvature of the spine, leading to uneven shoulders and hips. Pain and exaggerated lumbar curvature (choice A) are not specific manifestations of scoliosis. Tenderness and swelling of the spine (choice C) could indicate other conditions like infection or inflammation, not necessarily scoliosis. Limited range of motion of the back and a limp (choice D) are more indicative of musculoskeletal injuries or disorders, not scoliosis.
A nurse monitors fetal well-being by means of an external monitor. At the peak of the contractions, the fetal heart rate has repeatedly dropped 30 beats/min below the baseline. Late decelerations are suspected and the nurse notifies the physician. Which is the rationale for this action?
- A. A nuchal cord (cord around the neck) is associated with variable decelerations, not late decelerations.
- B. Variable decelerations (not late decelerations) are associated with cord compression.
- C. Late decelerations are a result of hypoxia. They are not reflective of the strength of maternal contractions.
- D. Late decelerations are associated with uteroplacental insufficiency and are a sign of fetal hypoxia. Repeated late decelerations indicate fetal distress.
Correct Answer: D
Rationale: The correct answer is D because late decelerations are associated with uteroplacental insufficiency, indicating fetal hypoxia. During contractions, the placenta may not be receiving enough oxygen and nutrients, leading to decreased oxygen supply to the fetus, resulting in late decelerations. Repeated late decelerations indicate ongoing fetal distress and the need for immediate intervention to prevent further complications. Choices A, B, and C are incorrect because they do not accurately reflect the characteristics and causes of late decelerations. A nuchal cord is associated with variable decelerations, not late decelerations. Variable decelerations are due to cord compression, not late decelerations. Late decelerations are indeed a result of hypoxia, but they are specifically related to uteroplacental insufficiency, not reflective of the strength of maternal contractions.
A 15-year-old client visits the clinic to get medical clearance to play a sport.
- A. "I will avoid showering at the gym."'
- B. "I can apply an antifungal cream daily."'
- C. "I should wear dark-colored socks."'
- D. "I should wear well-ventilated shoes."'
Correct Answer: D
Rationale: The correct answer is D: "I should wear well-ventilated shoes." This is because well-ventilated shoes help prevent fungal infections by keeping the feet dry and reducing moisture buildup, which is crucial for active individuals like athletes. Choice A is incorrect as avoiding showering at the gym is not a practical solution for preventing fungal infections. Choice B, applying antifungal cream daily, is reactive rather than preventive. Choice C, wearing dark-colored socks, does not directly address the issue of moisture and ventilation.