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A nurse is collecting data on a 3-year-old child with eczema in an outpatient center.
- A. "Cover the crib mattress with a plastic cover."'
- B. "Give the child a bubble bath for 20 min each day."'
- C. "Place a humidifier in the child's room."'
- D. "Dress the child in warm wool clothing in cold weather."'
Correct Answer: C
Rationale: The correct answer is C, "Place a humidifier in the child's room." This is because eczema can worsen with dry skin, and a humidifier can help maintain moisture in the air, preventing skin dryness. Choice A is incorrect as a plastic cover can trap heat and sweat, exacerbating eczema. Choice B is incorrect as bubble baths can irritate sensitive skin. Choice D is incorrect as wool clothing can be abrasive and trigger eczema flare-ups.
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A nurse is caring for a child with acute glomerulonephritis. The child has edema, hypertension, and gross hematuria. Which of the following is the most appropriate nursing intervention?
- A. Monitor the oxygen saturation every 4 hr.
- B. Teach the parents dietary restrictions regarding protein.
- C. Weigh the child daily and record intake and output.
- D. Counsel the parents about the need for follow-up.
Correct Answer: C
Rationale: The correct answer is C: Weigh the child daily and record intake and output. This intervention is crucial in monitoring fluid balance and kidney function in a child with acute glomerulonephritis. Daily weights help assess for fluid retention, while intake and output measurements help evaluate kidney function. Edema, hypertension, and gross hematuria are key symptoms of this condition, indicating the need for close monitoring.
Choice A is incorrect because monitoring oxygen saturation is not directly related to the management of acute glomerulonephritis. Choice B is also incorrect as dietary restrictions regarding protein are not the priority in this situation. Choice D is incorrect as counseling about follow-up is important but not the most immediate intervention needed.
A 17-year-old client delivered her first baby 8 hours ago. Which of the following is an indication that appropriate bonding is occurring? The client:
- A. makes eye contact with the baby.
- B. wonders why the baby cries so much.
- C. asks the nurse to help change the baby's diaper.
- D. asks the nurse if the baby is cute.
Correct Answer: A
Rationale: The correct answer is A: makes eye contact with the baby. This indicates appropriate bonding as eye contact fosters emotional connection and attachment between mother and baby. It shows the mother is engaging with her child, seeking to establish a bond. Choice B suggests lack of understanding of infant communication, choice C indicates practical caregiving rather than emotional bonding, and choice D focuses on the baby's appearance rather than emotional connection.
A woman in active labor receives a narcotic analgesic for pain control. If the narcotic is given a half an hour before delivery, which effect will the medication have on the infant?
- A. It will cause the infant's blood sugar to fall.
- B. It will cause the infant's respiratory rate to decrease.
- C. It will cause the infant's heart rate to increase.
- D. It will cause the infant's movements to be hyperactive.
Correct Answer: B
Rationale: The correct answer is B: It will cause the infant's respiratory rate to decrease. Narcotic analgesics can cross the placenta and affect the baby. These medications can depress the respiratory drive of the newborn, leading to decreased respiratory rate. This effect is particularly pronounced if the narcotic is given shortly before delivery when the drug levels in the infant's system are highest. The other choices are incorrect because: A) Narcotics are not known to directly affect blood sugar levels in infants. C) Narcotics typically cause a decrease, rather than an increase, in heart rate. D) Narcotics are more likely to cause sedation and decreased movements rather than hyperactivity in newborns.
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.
Which fetal structure is responsible for carrying oxygenated blood from the placenta to the fetus?
- A. Ductus arteriosus
- B. Umbilical artery
- C. Portal vein
- D. Umbilical vein
Correct Answer: D
Rationale: The correct answer is D: Umbilical vein. The umbilical vein carries oxygenated blood from the placenta to the fetus. This is because the placenta acts as the organ of gas exchange during fetal development. Oxygenated blood from the mother is transferred to the fetus through the umbilical vein. The other choices are incorrect because: A) Ductus arteriosus is a fetal blood vessel that connects the pulmonary artery to the aorta, bypassing the lungs. B) Umbilical artery carries deoxygenated blood from the fetus to the placenta. C) Portal vein carries nutrient-rich blood from the intestines to the liver, not from the placenta to the fetus.