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A newborn has been delivered. An Apgar score is given. What does this scoring system indicate?
- A. heart rate, respiratory effort, color, muscle tone, reflex irritability
- B. heart rate, bleeding, cyanosis, edema
- C. bleeding, reflex, edema
- D. respiratory effort, heart rate, seizures
Correct Answer: A
Rationale: The Apgar scoring system was put into place by Virginia Apgar, an anesthesiologist in New York, for the purpose of assessing newborns in the areas of heart rate, respiratory effort, color, muscle tone, and reflex irritability at 1, 5, and sometimes 10 minutes after birth.
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A client taking isotretinoin (Accutane) tells the nurse that she is pregnant. What should the nurse teach this client?
- A. Her pregnancy is threatened, and the fetus is at risk for teratogenesis.
- B. She has a reportable condition, and the pregnancy must be terminated.
- C. Accutane is a Category D drug, which means it is unsafe in pregnancy.
- D. Her pregnancy must be followed carefully by a genetic specialist.
Correct Answer: A
Rationale: Accutane is a Category X drug, which means pregnancy is contraindicated due to teratogenesis associated with the medication.
The nurse is caring for the client who received afterload internal radiotherapy (brachytherapy) for treatment of uterine cancer. The nurse manager evaluates that the nurse uses correct hazardous material precautions when noting that the nurse takes which action?
- A. Double-bags linens before removing them from the client's room
- B. Minimizes the amount of time spent in contact with the client
- C. Maintains a distance of 1 foot away from the client
- D. Wears lead gloves and apron and a dosimetry badge with client contact
Correct Answer: B
Rationale: Minimizing time spent with the client reduces radiation exposure, a key precaution in brachytherapy.
The mother calls the nurse to ask when her newborn will be brought back to her room to finish feeding. The mother states that a doctor came about 30 minutes ago to take the baby for an examination and has not returned with her baby. Which action should be taken by the nurse first?
- A. Check the unit for the infant
- B. Initiate procedures for possible newborn abduction
- C. Ask other staff if they saw any physicians on the unit
- D. Check to see if the doctor is still examining the Infant
Correct Answer: B
Rationale: The suspicious circumstance of a doctor taking the baby for 30 minutes warrants immediate initiation of abduction procedures to ensure the newborn's safety.
The nurse manager overhears multiple conversations on a hospital unit. Based on the statement made, the nurse manager should initiate the process for reporting incivility with which person?
- A. Charge nurse to the nurse, "I need to discuss the medication error you made yesterday."
- B. HCP to the nurse, "Tell me again what the client's vital signs were before I collapsed."
- C. Nurse to a coworker, "You forgot to document the client's noon glucometer reading."
- D. HCP to the client, "I can't do anything more for you; you don't follow my advice anyway."
Correct Answer: D
Rationale: The HCP's statement to the client is demeaning and uncivil, warranting a report for incivility.
The nursing student is discussing with a preceptor the delegation of tasks to an unlicensed assistive personnel (UAP). Assigning which of these tasks to a UAP indicates the student needs further teaching about the delegation process?
- A. Assist a client post cerebral vascular accident to ambulate
- B. Feed a 2 year-old in balanced skeletal traction
- C. Care for a client with discharge orders
- D. Collect a sputum specimen for acid fast bacillus
Correct Answer: C
Rationale: Care for a client with discharge orders. A registered nurse (RN) is the best person to do teaching or evaluation that is needed at time of discharge.