Nokea
Which action should the nurse include in the plan?
- A. Minimize noise in the newborn's environment.
- B. Swaddle the newborn loosely to allow free movement.
- C. Position the newborn supine with legs extended.
- D. Encourage frequent handling and stimulation.
Correct Answer: A
Rationale: The correct answer is A because minimizing noise in the newborn's environment is crucial for promoting rest and reducing stress. Newborns are highly sensitive to loud noises, which can disrupt their sleep and affect their overall well-being. By creating a quiet environment, the nurse helps the newborn to feel secure and comfortable, promoting better sleep and overall development.
Choice B is incorrect because swaddling the newborn loosely may pose a suffocation risk and restrict movement, which is not recommended. Choice C is incorrect as positioning the newborn supine with legs extended may increase the risk of sudden infant death syndrome (SIDS). Choice D is also incorrect as encouraging frequent handling and stimulation can overwhelm the newborn's developing nervous system and lead to increased stress.
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Select the findings that indicate the interventions have been effective.
- A. Client rates pain with contractions as a 3 on a scale of 0 to 10
- B. Contractions occurring every 2.5 to 3 minutes, lasting 60 to 70 seconds
- C. Accelerations present, no decelerations noted
- D. Heart rate 88/min
- E. Blood pressure 122/80 mm Hg
- F. Temperature 38° C(100.4° F)
Correct Answer: A,C
Rationale: Effective pain relief (client rates pain as 3) and normal FHR patterns indicate successful interventions.
After the nurse indicates chest pain protocol, which of the following is the priority diagnostic test?
- A. PT and INR
- B. 12 lead ECG
- C. Chest X-ray
- D. D-dimer test
Correct Answer: C
Rationale: The correct answer is C: Chest X-ray. When a patient presents with chest pain, a chest X-ray is crucial to evaluate for any acute cardiopulmonary conditions like pneumonia, pneumothorax, or aortic dissection. It helps identify any immediate life-threatening issues that require prompt intervention. PT and INR (A) are coagulation tests not typically indicated for acute chest pain. A 12-lead ECG (B) is important but usually done after the chest X-ray to assess for cardiac abnormalities. D-dimer test (D) is used to rule out pulmonary embolism, but it is not the priority test in the initial evaluation of chest pain.
A nurse is assessing a client who is postoperative and has a history of pulmonary embolism. Which of the following findings is the priority for the nurse to report to the provider?
- A. Dyspnea
- B. Pain at the surgical site
- C. Mild nausea
- D. Temperature of 37.5°C (99.5°F)
Correct Answer: A
Rationale: The correct answer is A: Dyspnea. Dyspnea in a postoperative client with a history of pulmonary embolism indicates a potential complication, such as a recurrent or new pulmonary embolism, which can be life-threatening. The nurse should report this finding to the provider immediately for further evaluation and intervention to prevent worsening respiratory distress and potential respiratory failure. Pain at the surgical site (choice B) is expected postoperatively and can be managed with appropriate pain medications. Mild nausea (choice C) is a common postoperative symptom and can be managed with antiemetic medications. A temperature of 37.5°C (99.5°F) (choice D) may indicate a mild fever, which can be monitored unless accompanied by other concerning symptoms.
Complete the sentence using the lists of options.The child is at highest risk for developing------------evidenced by the child's-----------
- A. compartment syndrome
- B. circulatory impairment
- C. abrasion and bruising
- D. paresthesia
- E. nerve damage
Correct Answer: B,D
Rationale: Circulatory impairment is evidenced by paresthesia (tingling), indicating compromised blood flow.
Which of the following laboratory values should the nurse monitor?
- A. Liver function tests
- B. kidney function tests
- C. hemoglobin and hematocrit
- D. serum sodium and potassium
Correct Answer: A
Rationale: The correct answer is A: Liver function tests. Monitoring liver function is crucial as it assesses the health of the liver, detecting any abnormalities or diseases. Liver function tests include assessing levels of enzymes, proteins, and bilirubin. Abnormal results can indicate liver damage or dysfunction. Monitoring kidney function (B) is important but not the priority in this scenario. Hemoglobin and hematocrit (C) are essential for assessing blood health but not specific to liver function. Serum sodium and potassium (D) are more related to electrolyte balance than liver function.