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The nurse is observing a staff member caring for a client who had a vaginal birth 30 minutes ago. The client is having difficulty with breastfeeding and is requesting assistance. The nurse should intervene if the staff member is observed
- A. providing supplemental formula feedings until improved breastfeeding occurs
- B. checking the newborn's position and sucking behavior during breastfeeding
- C. demonstrating to the client how to express breastmilk using the hand
- D. providing information on recognizing newborn hunger cues
Correct Answer: A
Rationale: Supplemental formula may undermine breastfeeding efforts early on. Checking position , demonstrating expression , and teaching hunger cues support breastfeeding.
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The school nurse suspects that a third grade child might have attention deficit hyperactivity disorder (ADHD). Prior to referring the child for further evaluation, the nurse should
- A. Observe the child's behavior on at least 2 occasions
- B. Consult with the teacher about how to control impulsivity
- C. Compile a history of behavior patterns and developmental accomplishments
- D. Compare the child's behavior with classic signs and symptoms
Correct Answer: C
Rationale: Compile a history of behavior patterns and developmental accomplishments. A comprehensive history is essential for accurate ADHD diagnosis.
The LPN/LVN is to assist the school nurse in scoliosis screening. What instructions should be given to the students?
- A. Wear a bathing suit under your clothes on the examination day.
- B. Bring a urine sample to school.
- C. Do not wash your hair the night before the exam.
- D. Wash your feet well the morning of the exam.
Correct Answer: A
Rationale: A bathing suit allows easy spinal visualization during scoliosis screening, ensuring modesty and efficiency.
A client who is pregnant at 30 weeks gestation comes to the prenatal clinic. Which of the following vaccines may be administered safely at this prenatal visit? Select all that apply
- A. Influenza injection
- B. Influenza nasal spray
- C. Measles, mumps, and rubella
- D. Tetanus, diphtheria, and pertussis
- E. Varicella
Correct Answer: A,D
Rationale: Influenza injection and Tdap are safe and recommended in pregnancy. Nasal spray , MMR , and varicella are live vaccines, contraindicated in pregnancy.
What principle of HIV disease should the nurse keep in mind when planning care for a newborn who was infected in utero?
- A. The disease will incubate longer and progress more slowly in this infant
- B. The infant is very susceptible to infections
- C. Growth and development patterns will proceed at a normal rate
- D. Careful monitoring of renal function is indicated
Correct Answer: B
Rationale: The infant is very susceptible to infections. HIV compromises the immune system, increasing susceptibility to opportunistic infections.
Which of the following tasks can the nurse assign to an unlicensed assistive personnel (UAP)?
- A. assisting a client with ambulating to the bathroom for the first time following surgery
- B. expiated client with dementia who has a serum glucose level of 70 mg/dL (3.9 mmol/L)
- C. explaining why incentive spirometer use is important to a client with postoperative pneumonia
- D. taking vital signs every 15 minutes on a client who was just transferred from the postanesthesia recovery unit
Correct Answer: D
Rationale: Taking vital signs is within UAP scope. First-time ambulation , hypoglycemia , and teaching require nursing judgment.