Nokea
The nurse should identify which of the following conditions as a possible cause of fetal bradycardia?
- A. Chorioamnionitis
- B. Maternal fever
- C. Fetal anemia
- D. Maternal hypoglycemia
Correct Answer: D
Rationale: Maternal hypoglycemia can lead to fetal bradycardia.
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Select the 5 actions the nurse should take.
- A. Provide frequent rest periods for the client.
- B. Restrict the client's sodium intake
- C. Advise the client to avoid the use of soap and alcohol-based lotions
- D. Place the client on a low-carbohydrate diet
- E. Place the client under contact isolation.
- F. Instruct the client to avoid blowing their nose forcefully
- G. Assess the client's level of orientation
Correct Answer: A,B,C,E,F,G
Rationale: The correct actions the nurse should take are A, B, C, E, F, and G. A: Providing rest periods promotes healing. B: Restricting sodium intake is crucial for certain health conditions. C: Avoiding soap and alcohol-based lotions can prevent skin irritation. E: Placing the client under contact isolation is necessary to prevent the spread of infection. F: Instructing the client to avoid blowing their nose forcefully prevents injury. G: Assessing the client's level of orientation is essential for monitoring their mental status. Other choices are incorrect because a low-carbohydrate diet (D) is not mentioned, and it is not a priority action in this scenario.
Which of the following actions should the nurse encourage the client and family to take as they adjust to their new roles?
- A. Implement firm but flexible boundaries in their relationship
- B. Encourage authoritative communication from the adult child
- C. Decrease socialization with extended relatives until roles are identified,
- D. Minimize open discussion regarding the changes to avoid embarrassment.
Correct Answer: A
Rationale: Boundaries foster healthy family dynamics during role adjustments.
The client asks the nurse if the medication can be given 2 hr. earlier. Which of the following statements should the nurse make?
- A. I can start the medication 30 minutes earlier.
- B. I can adjust the time and schedule for when it's convenient for you.
- C. I can infuse the medication at a faster rate.â€
- D. I have up to 2 hours after the usual schedule time to give you this medication.â€
Correct Answer: D
Rationale: The correct answer is D because it adheres to safe medication administration practices. The nurse should explain to the client that there is a window of up to 2 hours after the usual schedule time to administer the medication safely. This ensures that the medication remains effective while also preventing any potential harm from giving it too early or too late.
Choice A is incorrect because starting the medication 30 minutes earlier may not fall within the safe administration window. Choice B is incorrect because adjusting the time solely based on convenience may compromise the medication's effectiveness. Choice C is incorrect because infusing the medication at a faster rate could lead to adverse effects.
Which of the following findings require follow up? Select all that apply.
- A. WBC count
- B. Temperature
- C. Potassium level
- D. Breath sounds
- E. Blood pressure
Correct Answer: A,B,D,E
Rationale: These findings suggest infection and respiratory distress, requiring immediate follow-up.
Which of the following findings should the nurse expect?
- A. Head circumference exceeds chest circumference
- B. Palpable fontanels
- C. Natural loss of deciduous teeth
- D. Nontender, protruding abdomen
Correct Answer: D
Rationale: The correct answer is D: Nontender, protruding abdomen. This finding is expected in a child with kwashiorkor, a form of severe protein-energy malnutrition. The nontender, protruding abdomen is due to fluid accumulation in the abdomen (ascites) and the lack of muscle mass. This is a key characteristic of kwashiorkor. The other choices are incorrect because: A) Head circumference exceeding chest circumference is not a typical finding in children; B) Fontanels should be soft and flat in infants, not palpable; C) Natural loss of deciduous teeth occurs around age 6-12 years, not in infancy.