Nokea
When performing a breast assessment, the nurse is inspecting the woman’s skin for which of the following? Select all that apply.
- A. Color
- B. Thickening
- C. Size and symmetry
- D. Venous pattern
Correct Answer: A
Rationale: The correct answer is A: Color. When performing a breast assessment, inspecting the skin color is important to assess for any signs of redness, bruising, or discoloration which could indicate underlying issues. Thickening (B) is assessed through palpation, not inspection. Size and symmetry (C) is evaluated by comparing the breasts visually and through measurement. Venous pattern (D) is not typically a primary focus of skin inspection during a breast assessment.
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The nurse is providing education to parents of a child with cleft palate. What will the nurse instruct the parents to report immediately?
- A. Facial paralysis
- B. Ear infections
- C. Increasing intracranial pressure (ICP)
- D. Drooling
Correct Answer: B
Rationale: The correct answer is B: Ear infections. Parents of a child with a cleft palate should report ear infections immediately because children with cleft palate are at higher risk for developing ear infections due to issues with Eustachian tube function. Ear infections can lead to hearing loss if left untreated. Facial paralysis (A) is not directly related to cleft palate. Increasing ICP (C) is not typically associated with cleft palate. Drooling (D) is common in children with cleft palate and does not require immediate reporting unless there are other concerning symptoms present.
Reduction in congenital rubella is best accomplished by:
- A. Avoiding contact with young children when infections are prevalent
- B. Taking prophylactic antibiotics during the second half of pregnancy
- C. Testing the rubella titer at the first prenatal visit to determine immunity
- D. Immunizing susceptible women at least 28 days before they become pregnant
Correct Answer: D
Rationale: The correct answer is D because immunizing susceptible women at least 28 days before they become pregnant ensures protection against rubella during pregnancy, reducing the risk of congenital rubella syndrome in the fetus. This timing allows for the development of immunity before conception.
Avoiding contact with young children (A) does not directly prevent rubella transmission to pregnant women. Taking prophylactic antibiotics during pregnancy (B) is not recommended for rubella prevention. Testing rubella titer at the first prenatal visit (C) only assesses current immunity status but does not actively prevent congenital rubella.
A nurse working in a community clinic is teaching a client about chlamydia. Which statement made by the client would indicate a need for further instruction?
- A. Treatment is also required for individuals who are asymptomatic.
- B. Individuals can only spread the infection if symptomatic.
- C. All pregnant women should be screened for chlamydia.
- D. Any sexually active individuals can be infected with chlamydia.
Correct Answer: B
Rationale: The correct answer is B because it is incorrect. Chlamydia can be spread by individuals who are asymptomatic, so the statement that individuals can only spread it if symptomatic is inaccurate. Asymptomatic individuals can still transmit the infection to others. Therefore, this statement indicates a need for further instruction. Choices A, C, and D are all correct statements. Treatment is necessary for asymptomatic individuals to prevent complications, pregnant women should be screened for chlamydia to prevent transmission to the baby, and any sexually active individuals can indeed be infected with chlamydia.
Most congenital anomalies of the central nervous system (CNS) result from defects in the closure of the neural tube during fetal development. Which factor has the greatest impact on this process?
- A. Maternal diabetes
- B. Maternal folic acid deficiency
- C. Socioeconomic status
- D. Maternal use of anticonvulsant
Correct Answer: B
Rationale: The correct answer is B: Maternal folic acid deficiency. Folic acid is essential for neural tube closure. Deficiency can lead to neural tube defects in the fetus. Maternal diabetes (choice A) can increase the risk, but it's not the primary factor. Socioeconomic status (choice C) may indirectly impact nutrition but isn't directly related to neural tube closure. Maternal use of anticonvulsants (choice D) can increase the risk, but it's not as significant as folic acid deficiency in neural tube closure.
The nurse is caring for an Rh-negative mother on the postpartum unit. What scenario indicates the need to administer RhoGAM to this patient?
- A. She has had one Rh-negative child and is pregnant with an Rh-negative child.
- B. She has had an Rh-positive infant and is pregnant with an Rh-positive fetus.
- C. She has had an O-negative child and is pregnant with a B-negative child.
- D. She is a primipara with an O-negative child.
Correct Answer: B
Rationale: Rationale:
1. Rh-negative mother with Rh-positive infant: During delivery, fetal blood can mix with maternal blood leading to sensitization.
2. Sensitization can cause the mother's immune system to produce antibodies against Rh antigen.
3. RhoGAM is administered to prevent antibody formation in Rh-negative mothers carrying Rh-positive infants.
Summary:
- A: Incorrect. No risk of sensitization as both child and fetus are Rh-negative.
- B: Correct. Rh-negative mother with Rh-positive infant at risk for sensitization.
- C: Incorrect. Rh factor mismatch between children doesn't require RhoGAM.
- D: Incorrect. Being primipara or child's blood type doesn't warrant RhoGAM administration.