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A 3-month-old with myelomeningocele and atonic bladder is catheterized every 4hrs to prevent urinary retention. The home health nurse notes that the child has developed episodes of sneezing, urticarial, watery eyes, and a rash in the diaper area. What action is most important for the nurse to take?
- A. Auscultate the lungs for respiratory pneumonia.
- B. Change to latex-free gloves when handling infant.
- C. Draw blood to analyze for streptococcal infection.
- D. Apply zinc oxide to perineum with each diaper change.
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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A pregnant woman in her first trimester is experiencing watery vaginal discharge. What should the nurse tell her?
- A. Inform her that it is normal.
- B. Advise her to see a doctor immediately.
- C. Suggest using panty liners.
- D. Suggest a change in diet.
Correct Answer: A
Rationale: Informing the pregnant woman that watery vaginal discharge is normal during the first trimester is crucial to providing reassurance and reducing anxiety. This discharge, known as leukorrhea, is common during pregnancy due to increased estrogen levels and increased blood flow to the pelvic area. It helps maintain a healthy balance of bacteria in the vagina and protects the birth canal from infection. Advising the woman to see a doctor immediately may cause unnecessary alarm, while suggesting the use of panty liners can help manage the discharge comfortably. Suggesting a change in diet is not relevant to addressing watery vaginal discharge in this scenario.
The healthcare provider notes on the fetal monitor that a laboring client has a variable deceleration. Which action should the healthcare provider implement first?
- A. Assess cervical dilation.
- B. Change the client's position.
- C. Administer oxygen via facemask.
- D. Turn off the oxytocin infusion.
Correct Answer: B
Rationale: Changing the client's position is the priority intervention for variable decelerations as it can relieve pressure on the umbilical cord, potentially resolving the deceleration and improving fetal oxygenation. Assessing cervical dilation, administering oxygen via facemask, and turning off the oxytocin infusion are important interventions but addressing the fetal distress caused by variable decelerations takes precedence.
A newborn's parents tell the nurse that their baby is already trying to walk. How should the nurse respond?
- A. Encourage the parents to report this to the healthcare provider.
- B. Acknowledge the parents' observation.
- C. Schedule the newborn for further neurological testing.
- D. Explain the newborn's normal stepping reflex.
Correct Answer: D
Rationale: When parents report that their newborn is trying to walk, the nurse should understand that newborns exhibit a stepping reflex, which is a normal developmental response. Explaining this reflex to the parents helps them understand that it is a typical behavior seen in newborns rather than true attempts to walk. Encouraging the parents to report this to the healthcare provider (Choice A) may cause unnecessary concern since the stepping reflex is a normal part of newborn development. Acknowledging the parents' observation (Choice B) is a good communication strategy but providing education on the normal reflex is essential. Scheduling the newborn for further neurological testing (Choice C) is not indicated in this scenario as the stepping reflex is a typical finding in newborns.
When counseling a couple seeking information about conceiving, the LPN/LVN should know that ovulation usually occurs
- A. two weeks before menstruation.
- B. immediately after menstruation.
- C. immediately before menstruation.
- D. three weeks before menstruation.
Correct Answer: A
Rationale: Ovulation typically occurs about 14 days before the start of the next menstrual period. This timing allows for the released egg to travel down the fallopian tube where it may be fertilized by sperm, leading to conception. Understanding the timing of ovulation is crucial for couples trying to conceive to increase their chances of success.
A 36-week primigravida is admitted to labor and delivery with severe abdominal pain and bright red vaginal bleeding. Her abdomen is rigid and tender to touch. The fetal heart rate (FHR) is 90 beats/minute, and the maternal heart rate is 120 beats/minute. What action should the nurse implement first?
- A. Alert the neonatal team and prepare for neonatal resuscitation
- B. Notify the healthcare provider from the client's bedside
- C. Obtain written consent for an emergency cesarean section
- D. Draw a blood sample for stat hemoglobin and hematocrit
Correct Answer: B
Rationale: In this scenario, the priority action for the nurse is to notify the healthcare provider from the client's bedside. The clinical presentation of severe abdominal pain, bright red vaginal bleeding, rigid and tender abdomen, along with fetal bradycardia (FHR 90 bpm) and maternal tachycardia (120 bpm) indicates an urgent need for medical intervention. Notifying the healthcare provider promptly allows for immediate assessment and decision-making to address the critical condition and ensure timely and appropriate management for both the mother and fetus.