Nokea
A nurse is talking to the parents of a 3-year-old child about water safety precautions. Which of the following statements made by the parents indicates a need for clarification?
- A. We keep the toilet seat down at all times.
- B. We don't answer the phone during bath time.
- C. We empty all buckets filled with water.
- D. We have our child in swimming lessons.
Correct Answer: D
Rationale: The correct answer is D because enrolling a 3-year-old child in swimming lessons does not necessarily prevent drowning incidents. It is crucial for parents to understand that even with swimming lessons, active supervision around water is essential to prevent accidents. Keeping the toilet seat down (A), avoiding distractions during bath time (B), and emptying buckets filled with water (C) are all important water safety precautions to prevent drowning incidents. Swimming lessons are beneficial, but they should not replace vigilant supervision.
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A client is admitted to the hospital for induction of labor. Which are the main indications for labor induction?
- A. Placenta previa and twins
- B. Pregnancy-induced hypertension and postterm fetus
- C. Breech position and prematurity
- D. Cephalopelvic disproportion and fetal distress
Correct Answer: B
Rationale: The correct answer is B: Pregnancy-induced hypertension and postterm fetus. Labor induction is commonly indicated in cases of pregnancy-induced hypertension to prevent complications such as preeclampsia. Postterm fetus is another common indication to prevent risks associated with a prolonged pregnancy, such as stillbirth. Placenta previa, twins, breech position, prematurity, cephalopelvic disproportion, and fetal distress are not typically primary indications for labor induction. Placenta previa may require a cesarean section, twins may be delivered vaginally or by C-section, breech position may require external cephalic version or C-section, prematurity may necessitate medical management, cephalopelvic disproportion may require a C-section, and fetal distress may necessitate immediate delivery but not necessarily labor induction.
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.
A woman enters the birthing center in active labor. She tells the nurse that her membranes ruptured 26 hours ago. The nurse immediately takes the client's vital signs. Which is the rationale for the nurse's actions?
- A. Pulse rates rise the longer the membranes are ruptured
- B. Respiratory rates decrease due to lack of fluid in the uterus
- C. Prolonged rupture of membranes can lead to transient hypertension
- D. Infection is a complication of prolonged rupture of membranes
Correct Answer: D
Rationale: The correct answer is D. When the membranes rupture, it increases the risk of infection as it provides a direct pathway for bacteria to enter the uterus. Taking vital signs is crucial to monitor for signs of infection such as fever, tachycardia, and hypotension. Elevated temperature and increased heart rate can indicate an infection. Choice A is incorrect because pulse rate may not necessarily rise with prolonged rupture of membranes. Choice B is also incorrect as respiratory rates are not directly affected by ruptured membranes. Choice C is incorrect as prolonged rupture can lead to infection rather than transient hypertension.
A nurse provided discharge teaching to new parents on how to care for their newborn following circumcision. Which of the following statements by the parents indicates the need for further clarification?
- A. I should not remove the yellow exudate on the end of the penis.
- B. I will clean his penis with each diaper change.
- C. The circumcision will heal completely within a couple of weeks.
- D. I can give him a tub bath in two days.
Correct Answer: D
Rationale: The correct answer is D. Giving the newborn a tub bath in two days after circumcision could increase the risk of infection as the circumcision wound needs time to heal. A sponge bath is recommended until the wound is completely healed. Choice A is correct because yellow exudate is normal during the healing process. Choice B is correct as keeping the area clean is important. Choice C is correct as circumcision typically heals within a couple of weeks.
A nurse is preparing to collect a blood specimen from a newborn via a heel stick. Which of the following techniques should the nurse use to help minimize the pain of the procedure for the newborn?
- A. Apply a cool pack for 10 minutes to the heel prior to the puncture
- B. Request a prescription for IM analgesic
- C. Use a manual lancet blade to pierce the skin
- D. Place the newborn skin to skin on the mother’s chest
Correct Answer: D
Rationale: The correct answer is D: Place the newborn skin to skin on the mother's chest. This technique, known as kangaroo care, helps minimize pain during procedures by providing comfort, warmth, and security to the newborn. The close physical contact with the mother can reduce stress and promote relaxation, leading to decreased perception of pain. Additionally, the release of oxytocin during skin-to-skin contact can further alleviate discomfort for the newborn.
Applying a cool pack (choice A) may actually increase pain and vasoconstriction, making the heel stick more uncomfortable. Requesting an IM analgesic (choice B) is unnecessary and may expose the newborn to unnecessary medications. Using a manual lancet blade (choice C) can be painful and may not provide the same comfort and pain relief as skin-to-skin contact.