Nokea
Which treatment is a nursing priority when providing care for an infant diagnosed with bacterial meningitis?
- A. Initiate cardiorespiratory monitoring.
- B. Initiate intravenous fluids.
- C. Observe respiratory isolation.
- D. Administer antibiotic therapy.
Correct Answer: D
Rationale: The first nursing priority is the implementation of antibiotic therapy, which prohibits the microbial damage to the neurologic system through the cerebral spinal fluid. Immediate treatment with antibiotics can prevent serious complications such as death, deafness, reduced cognitive ability, and seizures.
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A nurse is reinforcing teaching with the parents of an infant diagnosed with recurrent otitis media. Which of the following is appropriate teaching to include?
- A. Give the child an over-the-counter antihistamine when the symptoms begin.
- B. Hold the child in an upright position while feeding.
- C. Talk with the primary health care provider about performing a tonsillectomy.
- D. Apply a warm compress over the affected ear to provide comfort.
Correct Answer: B
Rationale: The correct answer is B: Hold the child in an upright position while feeding. This is important because feeding the infant in an upright position can help prevent reflux of milk into the Eustachian tube, reducing the risk of otitis media. This position helps to promote proper drainage and ventilation of the middle ear, decreasing the likelihood of infection.
Incorrect answers:
A: Giving the child an over-the-counter antihistamine is not appropriate for otitis media, as it is typically caused by bacterial infection, not allergies.
C: Tonsillectomy is not a first-line treatment for otitis media. It is usually considered if the child has recurrent tonsillitis, not otitis media.
D: Applying a warm compress over the affected ear may provide comfort but does not address the underlying cause or prevention of otitis media.
A nurse is discussing the use of condoms with a female client. Which of the following statements by client represents a need for further teaching?
- A. My partner will put the condom on while his penis is erect.
- B. I will remove the condom 30 minutes after intercourse.
- C. My partner should leave an empty space at the tip.
- D. I can use spermicidal gels or creams to increase effectiveness.
Correct Answer: B
Rationale: The correct answer is B because condoms should be removed immediately after intercourse to prevent leakage of semen. Leaving the condom on for 30 minutes increases the risk of pregnancy and STIs. Choice A is correct as condoms should be put on when the penis is erect. Choice C is correct as leaving a space at the tip allows room for semen collection. Choice D is incorrect as spermicidal gels or creams are not recommended due to potential irritation and increased risk of STIs.
Which assessment finding indicates that placental separation has occurred during the third stage of labor?
- A. Decreased vaginal bleeding
- B. Contractions stop
- C. Maternal shaking and chills
- D. Lengthening of the umbilical cord
Correct Answer: D
Rationale: The correct answer is D: Lengthening of the umbilical cord. This indicates placental separation as the placenta detaches from the uterine wall, causing the cord to lengthen. A: Decreased vaginal bleeding is incorrect as bleeding typically increases due to separation. B: Contractions stopping is not indicative of placental separation but can occur after the placenta is delivered. C: Maternal shaking and chills are signs of postpartum shivering, not placental separation.
The nurse notices a variable deceleration on a fetal monitor strip. Which nursing action is appropriate?
- A. Instruct the mother to breathe slowly because this is a sign of hyperventilation
- B. Decrease the amount of Pitocin because this is a sign of hypertonic uterine contractions
- C. Turn the woman onto her left side to relieve pressure on the umbilical cord
- D. Reduce the oral and IV fluids to decrease circulatory overload
Correct Answer: C
Rationale: The correct answer is C: Turn the woman onto her left side to relieve pressure on the umbilical cord. Variable decelerations are associated with umbilical cord compression. Turning the woman onto her left side can help relieve pressure on the cord, improving fetal oxygenation. This position change is a non-invasive, quick intervention that can potentially resolve the variable decelerations.
Choice A is incorrect because variable decelerations are not typically associated with hyperventilation. Choice B is incorrect as decreasing Pitocin may not directly address the underlying cause of the variable decelerations. Choice D is incorrect because reducing fluids may not address the immediate concern of umbilical cord compression.
A 38 week gestation newborn weighs 4020 grams, is sluggish, and has limp muscle tone. The baby experienced a broken clavicle during delivery. Based on this information, which can the nurse conclude about the baby?
- A. Neonatal abstinence symptoms
- B. Large for gestational age
- C. Congenital cardiac defect
- D. Respiratory depression
Correct Answer: B
Rationale: The correct answer is B: Large for gestational age. A newborn weighing 4020 grams at 38 weeks is considered large for gestational age. The sluggishness and limp muscle tone can be attributed to the baby's size, which can make movement more challenging. The broken clavicle could have occurred during delivery due to the baby's size and the forces involved. Neonatal abstinence symptoms (choice A) typically present with irritability, tremors, and poor feeding, not sluggishness. Congenital cardiac defects (choice C) usually manifest with cyanosis, tachypnea, and poor feeding. Respiratory depression (choice D) is characterized by poor respiratory effort, not sluggishness and limp muscle tone.