Nokea
Which of the following conditions should the nurse identify as being consistent with the adolescent's assessment findings? For each finding click to specify if the assessment findings are consistent with trichomoniasis, gonorrhea, or candidiasis. Each finding may support more than one disease process.
- A. Abdominal pain.
- B. Greenish discharge.
- C. Diabetes.
- D. Pain on urination.
- E. Absence of condom.
Correct Answer: B, D
Rationale: The correct answer is B, D . Abdominal pain (A) is not specific to any of the given conditions. Diabetes (C) is not directly related to the assessment findings provided. Absence of condom (E) is not an assessment finding, but a behavior. Trichomoniasis is characterized by greenish discharge, and pain on urination can be a symptom of both gonorrhea and trichomoniasis.
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A nurse is administering a hepatitis B vaccine to a newborn. Which of the following actions should the nurse take?
- A. Administer the injection into the vastus lateralis muscle.
- B. Vigorously massage the site following the injection.
- C. Insert the needle at a 45° angle for injection.
- D. Use a 21-gauge needle for the injection.
Correct Answer: A
Rationale: The correct answer is A: Administer the injection into the vastus lateralis muscle. For newborns, the vastus lateralis muscle is the preferred site for intramuscular injections due to its larger muscle mass and minimal nerve endings, reducing the risk of injury and increasing absorption. This site is recommended by healthcare guidelines for administering vaccines to infants to ensure proper absorption and effectiveness. The other choices are incorrect because vigorously massaging the site (B) can cause pain and tissue damage, inserting the needle at a 45° angle (C) may not reach the muscle and can cause subcutaneous injection, and using a 21-gauge needle (D) is not specific to the site and age group, potentially causing discomfort and inadequate absorption.
A nurse is providing teaching to a client who is at 35 weeks of gestation and has a prescription for an amniocentesis. Which of the following client statements indicates an understanding of the teaching?
- A. I should empty my bladder before the procedure.
- B. I will be lying on my side during the procedure.
- C. I will be asleep during the procedure.
- D. I should start fasting 24 hours before the procedure.
Correct Answer: A
Rationale: The correct answer is A. Emptying the bladder before amniocentesis helps prevent injury to the bladder during the procedure. This statement shows understanding of the importance of bladder emptying for safety and accuracy.
B: Incorrect. The client is typically lying on their back during amniocentesis.
C: Incorrect. The client is awake during the procedure.
D: Incorrect. Fasting is not required for amniocentesis.
A nurse is caring for a client who is at 36 weeks of gestation and has methicillin-resistant Staphylococcus aureus. Which of the following types of isolation precautions should the nurse initiate?
- A. Droplet
- B. Contact
- C. Protective environment
- D. Airborne
Correct Answer: B
Rationale: The correct answer is B: Contact precautions. Methicillin-resistant Staphylococcus aureus (MRSA) is typically spread through direct contact with contaminated skin or surfaces. Therefore, the nurse should initiate contact precautions to prevent the spread of infection. This includes wearing gloves and a gown when providing care to the client, as well as ensuring proper hand hygiene.
Choice A (Droplet precautions) is incorrect because MRSA is not transmitted through droplets in the air. Choice C (Protective environment) is incorrect as this type of isolation is used for clients who are immunocompromised to protect them from environmental pathogens. Choice D (Airborne precautions) is incorrect as MRSA is not transmitted through the airborne route.
A nurse is planning care for a client who is 1 hr postpartum and has peripartum cardiomyopathy. Which of the following actions should the nurse plan to take?
- A. Obtain a prescription for misoprostol.
- B. Assess blood pressure twice daily.
- C. Restrict daily oral fluid intake.
- D. Administer an IV bolus of lactated Ringer's.
Correct Answer: B
Rationale: The correct answer is B: Assess blood pressure twice daily. This is crucial as peripartum cardiomyopathy can lead to heart failure and hypertension, affecting the client's blood pressure. Monitoring blood pressure twice daily allows for early detection of any changes and timely intervention. Obtaining a prescription for misoprostol (A) is not indicated as it is used for preventing gastric ulcers, not related to peripartum cardiomyopathy. Restricting oral fluid intake (C) may worsen the client's condition as adequate hydration is important for cardiac function. Administering an IV bolus of lactated Ringer's (D) could potentially worsen fluid overload and exacerbate heart failure.
A nurse is assessing a newborn following a forceps-assisted birth. Which of the following clinical manifestations should the nurse identify as a complication of this birth method?
- A. Polycythemia
- B. Hypoglycemia
- C. Bronchopulmonary dysplasia
- D. Facial palsy
Correct Answer: D
Rationale: The correct answer is D: Facial palsy. Forceps-assisted birth can put pressure on the baby's face, potentially leading to facial nerve injury and resulting in facial palsy. This occurs due to the compression of the facial nerve during delivery. Other choices are incorrect: A - Polycythemia is not directly related to forceps-assisted birth. B - Hypoglycemia is more commonly associated with maternal diabetes or prematurity. C - Bronchopulmonary dysplasia is a lung condition primarily seen in premature infants requiring mechanical ventilation or oxygen therapy. In summary, facial palsy is the most likely complication following a forceps-assisted birth due to the pressure exerted on the baby's face during delivery.