Nokea
A 17-year-old client delivered her first baby 8 hours ago. Which of the following is an indication that appropriate bonding is occurring? The client:
- A. makes eye contact with the baby.
- B. wonders why the baby cries so much.
- C. asks the nurse to help change the baby's diaper.
- D. asks the nurse if the baby is cute.
Correct Answer: A
Rationale: The correct answer is A: makes eye contact with the baby. This indicates appropriate bonding as eye contact fosters emotional connection and attachment between mother and baby. It shows the mother is engaging with her child, seeking to establish a bond. Choice B suggests lack of understanding of infant communication, choice C indicates practical caregiving rather than emotional bonding, and choice D focuses on the baby's appearance rather than emotional connection.
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Which condition must occur in order for identical (monozygotic) twins to develop?
- A. One sperm fertilizes two ova
- B. Two sperm fertilize two ova
- C. One sperm fertilizes one ovum
- D. Two sperm fertilize one ovum
Correct Answer: C
Rationale: The correct answer is C: One sperm fertilizes one ovum. Identical twins result from the fertilization of a single egg by a single sperm, leading to the formation of a zygote that later splits into two embryos. This process results in genetically identical individuals. Choices A, B, and D involve multiple fertilization events, which would lead to fraternal (dizygotic) twins with different genetic compositions. Therefore, the only condition that can lead to the development of identical twins is when one sperm fertilizes one ovum.
A nurse is reinforcing teaching with the parent of an infant who has club feet with bilateral casts.
- A. "Check the toes for any swelling or discoloration."'
- B. "Monthly recasting should be scheduled with the orthopedist."'
- C. "Use a heated fan or dryer to facilitate the drying of the cast."'
- D. "Give the baby Tylenol every 4 hr to help with pain."'
Correct Answer: A
Rationale: The correct answer is A because checking the toes for swelling or discoloration is crucial in monitoring circulation and preventing complications like pressure sores. Choice B is incorrect as casts are typically changed more frequently. Choice C is incorrect as heat can cause burns. Choice D is incorrect as giving Tylenol every 4 hours without a physician's recommendation is not advisable for pain management in infants.
The parents of a 5-month-old infant state that their infant seems to eat very little. Most of the food comes out of the infant's mouth and onto his clothes.
- A. "Give the baby a bottle of formula before solid food to assure adequate caloric intake."'
- B. "Stop the solid foods and try again when the baby is 12 months old."'
- C. "Put the cereal in a bottle and feed the baby through a nipple with a large hole."'
- D. "Place the food in the back of the baby's mouth using a long-handled spoon."'
Correct Answer: D
Rationale: The correct answer is D because at 5 months, infants are typically ready to start experimenting with solid foods. Placing the food in the back of the baby's mouth using a long-handled spoon helps prevent the baby from pushing the food out with their tongue reflex, allowing for more successful feeding. This method also encourages the baby to learn how to swallow solids properly. Choice A is incorrect as giving formula before solid food won't address the feeding issue. Choice B is incorrect as stopping solid foods until 12 months can hinder the baby's developmental milestones. Choice C is incorrect as feeding cereal in a bottle can increase the risk of choking and doesn't address the underlying issue of feeding difficulty.
During the active phase of labor, the membranes rupture and the nurse notes green amniotic fluid. Which nursing action should be initiated immediately?
- A. Call the physician.
- B. Replace the soiled underpad.
- C. Test the fluid with pH (Nitrazine) paper.
- D. Assess fetal heart rate.
Correct Answer: D
Rationale: The correct answer is D: Assess fetal heart rate. This is important because green amniotic fluid indicates meconium staining, which can be a sign of fetal distress. Assessing the fetal heart rate immediately will help determine the baby's well-being. Calling the physician (choice A) may be necessary but assessing the fetal heart rate should be the priority. Replacing the underpad (choice B) can wait until after assessing the fetal heart rate. Testing the fluid with pH paper (choice C) may confirm the presence of meconium but assessing the fetal heart rate is more urgent.
Which of the following physical manifestations of a client with anorexia nervosa best indicates compliance with the treatment plan of care?
- A. "A weekly weight gain of 1 kg (2.2 lb)"'
- B. "Daily bowel movements that are soft"'
- C. "Return of regular menstrual periods"'
- D. "Improvement of the oral mucosa"'
Correct Answer: A
Rationale: The correct answer is A: "A weekly weight gain of 1 kg (2.2 lb)". In anorexia nervosa, weight restoration is a key goal of treatment to address malnutrition and restore physiological functioning. A weekly weight gain of 1 kg indicates the client is consuming adequate nutrition and their body is responding appropriately to treatment. This physical manifestation suggests the client is compliant with the treatment plan.
Choice B, daily bowel movements that are soft, is not necessarily a direct indicator of compliance with the treatment plan for anorexia nervosa. While bowel movements can be influenced by dietary changes, they are not as specific or reliable as weight gain in assessing treatment compliance.
Choice C, return of regular menstrual periods, is a potential physical manifestation of improved health in anorexia nervosa, but it may not be the best indicator of compliance with the treatment plan, as it can be influenced by various factors.
Choice D, improvement of the oral mucosa, is important for