Nokea
A 38-week primigravida who works at a desk job and sits at a computer for 8 hours each day tells the nurse that her feet have begun to swell. Which instruction would be most effective in preventing pooling of blood in the lower extremities?
- A. Wear support stockings.
- B. Reduce salt in her diet.
- C. Move about every hour.
- D. Avoid constrictive clothing.
Correct Answer: C
Rationale: During pregnancy, especially in the third trimester, it is common for women to experience swelling due to decreased circulation. Encouraging the patient to move about every hour helps prevent blood pooling in the lower extremities by promoting circulation. This simple activity can help alleviate swelling and discomfort associated with prolonged sitting.
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A father watching the admission of his newborn to the nursery notices that eye ointment is placed in the infant's eyes. He asks what is the purpose of the ointment. The nurse would be correct in stating that the purpose of the ointment is:
- A. Prevent eye infection.
- B. Dilate the pupil so the red reflex can be visualized.
- C. Clear the infant's vision.
- D. Prevent herpes infection.
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The nurse is conducting postpartum teaching with a mother who is breastfeeding her infant. When discussing birth control which method should the nurse recommend to this client as best for her to use in preventing unwanted pregnancy?
- A. Breastfeed exclusively at least every 3 to 4 hours.
- B. Condoms and contraceptive foam or gel.
- C. Rhythm method (natural family planning).
- D. Combined estrogen-progesterone oral contraceptives.
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
One hour after giving birth to an 8-pound infant, a client's lochia rubra has increased from small to large, and her fundus is boggy despite massage. The client's pulse is 84 beats/minute, and blood pressure is 156/96. The healthcare provider prescribes Methergine 0.2 mg IM 1. What action should the healthcare provider take immediately?
- A. Give the medication as prescribed and monitor for efficacy.
- B. Encourage the client to breastfeed rather than bottle-feed.
- C. Have the client empty her bladder and massage the fundus.
- D. Call the healthcare provider to question the prescription.
Correct Answer: D
Rationale: The correct action for the healthcare provider to take immediately is to call the healthcare provider to question the prescription. Methergine is contraindicated in clients with hypertension due to its potential to elevate blood pressure further. In this scenario, the client's blood pressure is already elevated at 156/96, making it unsafe to administer Methergine. The LPN/LVN should advocate for the client's safety by questioning the prescription to prevent potential harm.
During the newborn admission assessment, the nurse palpates the newborn's scrotum and does not feel the testicles. Which assessment technique should the nurse perform next to verify the absence of testes?
- A. Observe the urethral opening on the surface of the penis when the newborn voids.
- B. Perform transillumination of the scrotal sac to visualize shadows of the testes.
- C. Use a fingertip to palpate the inguinal canal for a retractile or undescended testis.
- D. Measure the size of the scrotal sac for length and width.
Correct Answer: C
Rationale: If the testes are not palpated in the scrotum, the next step is to check the inguinal canal for a retractile or undescended testis. This technique allows the nurse to determine if the testes are located within the inguinal canal rather than the scrotum. It is essential to assess for the presence of testes in the inguinal canal to ensure proper diagnosis and management of any potential issues related to testicular positioning.
The healthcare provider prescribes Amoxicillin 500mg PO every 8hrs for a child who weighs 22 pounds. The available suspension is labeled Amoxicillin Suspension 250mg/5ml. The recommended maximum dose is 50mg/kg/24hr. How many mL should the nurse administer in a single dose based on the child's weight?
- A. 10mL
- B. 15mL
- C. 7.5mL
- D. 5mL
Correct Answer: A
Rationale: To calculate the dose for the child weighing 22 pounds, first convert the weight to kg: 22 lbs · 2.2 = 10 kg. The maximum dose based on weight would be 10 kg 50 mg/kg/24hr = 500 mg/24hr. Since the medication is prescribed every 8 hours, the dose for each administration would be 500 mg · 3 doses = 166.67 mg. As the available suspension is 250mg/5ml, the nurse should administer 166.67 mg · 250 mg/mL = 0.67 mL per dose. However, since it's not practical to administer a fraction of a milliliter, the nurse should round up to the nearest appropriate dose, which is 10mL.