Nokea
A 20-year-old female client delivers a stillborn infant. Following the delivery, an appropriate response by the labor nurse to the question, 'Why did this happen to my baby?' is:
- A. It's God's will. It was probably for the best. There was something probably wrong with your baby.'
- B. You're young. You can have other children later.'
- C. I know your other children will be a great comfort to you.'
- D. I can see you're upset. Would you like to see and hold your baby?'
Correct Answer: D
Rationale: The mother and the father require Wsupport; the nurse should not minimize their grief in this situation. Attachment to this infant occurs during the pregnancy for both the mother and father. Another child cannot replace this child. Attachment to this infant occurs during the pregnancy for both the mother and father. Siblings will not replace their feelings or minimize their loss of this infant. Holding and viewing the infant decreases denial and may facilitate the grief process. The nurse should prepare family members for how the infant appears ('she is bruised') and provide support.
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The charge nurse is formulating a discharge teaching plan for a client with mild preeclampsia. The nurse should give priority to:
- A. Teaching the client to report a nosebleed
- B. Instructing the client to maintain strict bed rest
- C. Telling the client to notify the doctor of pedal edema
- D. Advising the client to avoid sodium sources in the diet
Correct Answer: A
Rationale: Nosebleeds in preeclampsia may indicate severe hypertension or coagulopathy, requiring immediate reporting. Pedal edema is common, bed rest is not always needed, and sodium restriction is secondary.
A 3-year-old child is admitted with a diagnosis of possible noncommunicating hydrocephalus. What is the first symptom that indicates increased intracranial pressure?
- A. Bulging fontanelles
- B. Seizure
- C. Headache
- D. Ataxia
Correct Answer: C
Rationale: Headache is the earliest symptom of increased intracranial pressure in children, preceding other signs like seizures or ataxia.
A client who had major abdominal surgery is having delayed healing of the wound. Which laboratory test result would most closely correlate with this problem?
- A. Decreased albumin
- B. Decreased creatinine
- C. Increased calcium
- D. Increased sodium
Correct Answer: A
Rationale: Decreased albumin indicates protein deficiency, impairing tissue repair and delaying wound healing. Decreased creatinine (B) reflects renal function, increased calcium (C) affects bones, and increased sodium (D) affects fluid balance, not healing directly.
The nurse has been assigned a client who delivered a 6-lb, 12-oz baby boy vaginally 40 minutes ago. The initial assessment of greatest importance for this client would be:
- A. Length of her labor
- B. Type of episiotomy
- C. Amount of IV fluid to be infused
- D. Character of the fundus
Correct Answer: D
Rationale: The length of labor has little bearing on the fourth stage of labor. The type of labor and delivery is significant. The type of episiotomy will affect the client's comfort level. However, the nurse's assessment and implementations center on prevention of hemorrhage during the fourth stage of labor. The amount of bleeding from the episiotomy or hematoma formation is of higher priority than the type of episiotomy. The amount of IV fluid to be infused is a nursing function to be attended to; however, it is lower in priority than determining if hemorrhaging is occurring. Character of the fundus would be the priority nursing assessment because changes in uterine tone may identify possible postpartum hemorrhage.
The nurse is caring for a client with a history of psoriasis. The nurse should expect the client to have:
- A. Scaly plaques
- B. Joint swelling
- C. Fever
- D. Chest pain
Correct Answer: A
Rationale: Psoriasis causes scaly, silvery plaques due to rapid skin cell turnover, a hallmark symptom.