A 17-year-old unmarried, pregnant client with drug addiction is a high school dropout, homeless, and has a history of past abuse arrives at the clinic for her first prenatal visit. Which findings should the nurse document as health risk factors for the client? (Select all that apply)
- A. age
- B. school dropout
- C. drug addiction
- D. All of the above
Correct Answer: D
Rationale: All these factors - age, school dropout, drug addiction - are significant health risk factors for the client. Being young, a high school dropout, and struggling with drug addiction can lead to various complications during pregnancy, such as poor prenatal outcomes and social challenges. These factors can impact the client's overall health and well-being, highlighting the importance of addressing them during prenatal care.
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A primipara with a breech presentation is in the transition phase of labor. The nurse visualizes the perineum and sees the umbilical cord extruding from the introitus. In which position should the nurse place the client?
- A. Supine with the foot of the bed raised.
- B. On the left side with legs elevated.
- C. On the right side with legs elevated.
- D. Prone with head elevated.
Correct Answer: A
Rationale: In the scenario of a primipara with a breech presentation and a prolapsed umbilical cord, the nurse should place the client in the supine position with the foot of the bed raised (Trendelenburg position). This position helps alleviate gravitational pressure by the fetus on the cord, preventing compression and reducing the risk of cord prolapse complications. Placing the client on the left or right side with legs elevated or in a prone position with the head elevated would not be appropriate in this situation, as they do not effectively relieve the pressure on the umbilical cord.
The healthcare professional is developing a program to educate parents on the importance of immunizations. Which topic should be prioritized?
- A. the benefits of immunizations
- B. the potential side effects of vaccines
- C. the immunization schedule
- D. ways to comfort children during vaccinations
Correct Answer: A
Rationale: Prioritizing the benefits of immunizations is crucial in helping parents comprehend the significance of vaccines in safeguarding their children against preventable diseases. Understanding the positive impact of immunizations can alleviate concerns and misconceptions that parents may have, ultimately encouraging them to make informed decisions regarding their children's health. Discussing potential side effects (choice B) is important but should come after highlighting the benefits to avoid instilling unnecessary fear. While the immunization schedule (choice C) is essential information, it may be overwhelming if presented as the initial focus. Comforting children during vaccinations (choice D) is valuable but secondary to ensuring parents understand the benefits of immunizations.
The public health nurse is preparing to administer flu vaccines at a community center. Which group should the nurse prioritize for vaccination?
- A. children under 5 years old
- B. adults aged 50-65
- C. pregnant women
- D. healthcare workers
Correct Answer: C
Rationale: Pregnant women should be prioritized for flu vaccination as they are at higher risk for complications from the flu. During pregnancy, changes in the immune, heart, and lung functions make pregnant women more susceptible to severe illness from the flu. Vaccinating pregnant women not only protects them but also provides passive immunity to their newborns. Children under 5, adults aged 50-65, and healthcare workers are important groups for vaccination but do not have the same level of increased risk for flu complications as pregnant women.
A teenage boy with a history of recurring atopic dermatitis (eczema) tells the school nurse that he wants to play high school football. Which action should the nurse take?
- A. encourage the teenager to join the swim team instead of the football team
- B. notify the parents of the problems associated with perspiration for those with eczema
- C. tell the teenager to shower with a non-perfumed soap immediately after practice
- D. inform the football coach of the teenager's skin condition and its manifestations
Correct Answer: C
Rationale: The correct action for the nurse to take is to advise the teenager to shower with a non-perfumed soap immediately after practice. This recommendation can help reduce the risk of eczema flare-ups by removing sweat and irritants from the skin. Choice A is incorrect as it does not address the specific concerns related to eczema and football. Choice B, notifying the parents of perspiration problems, is not as direct as instructing the teenager on proper skincare. Choice D, informing the football coach, is not the most immediate and relevant action to address the teenager's individual needs.
The healthcare provider is inspecting the external eye structures of a client. Which finding is a normal racial variation?
- A. Blue sclerae.
- B. Brown macules on the sclerae.
- C. Slightly yellow sclerae in an African-American client.
- D. Conjunctival pallor.
Correct Answer: C
Rationale: The slightly yellow color of the sclera is a normal racial variation found in the African-American population. Blue sclerae (Choice A) are associated with osteogenesis imperfecta, not a normal racial variation. Brown macules on the sclerae (Choice B) may indicate issues like melanoma or melanosis but are not a normal racial variation. Conjunctival pallor (Choice D) suggests anemia or decreased blood flow but is not a normal racial variation.