Nokea
A baby is circumcised. Immediate postoperative care should include:
- A. Applying a loose diaper
- B. Keeping the baby NPO for 4 hours to avoid vomiting
- C. Changing the dressing frequently using dry, sterile gauze
- D. Taking the baby to his mother for cuddling
Correct Answer: D
Rationale: A pressure diaper should be applied to discourage hemorrhage. The baby can be fed by his mother soon after the procedure, once it is assessed that he is not in any distress and is stable. Dressing changes should not be dry. Dry dressing will stick. Cuddling after the procedure will hopefully quiet the baby. Feeding is also important if his feeding was withheld prior to the procedure or it is time for a feeding.
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The client is admitted with a diagnosis of gastroenteritis. Which precaution should the nurse implement?
- A. Standard precautions
- B. Contact precautions
- C. Droplet precautions
- D. Airborne precautions
Correct Answer: B
Rationale: Gastroenteritis is often caused by pathogens like norovirus, requiring contact precautions to prevent fecal-oral transmission. Standard precautions are insufficient, and droplet or airborne are not indicated.
Prenatal clients are routinely monitored for early signs of pregnancy-induced hypertension (PIH). For the prenatal client, which of the following blood pressure changes from baseline would be most significant for the nurse to report as indicative of PIH?
- A. 136/88 to 144/93
- B. 132/78 to 124/76
- C. 114/70 to 140/88
- D. 140/90 to 148/98
Correct Answer: C
Rationale: PIH is indicated by a systolic increase of 30 mm Hg or diastolic increase of 15 mm Hg; 114/70 to 140/88 shows a 26 mm Hg systolic and 18 mm Hg diastolic change, most significant for PIH.
A client has developed diabetes insipidus after removal of a pituitary tumor. Which finding would the nurse expect?
- A. Polyuria
- B. Hypertension
- C. Polyphagia
- D. Hyperkalemia
Correct Answer: A
Rationale: Diabetes insipidus causes polyuria due to deficient antidiuretic hormone, leading to excessive water loss. Hypertension (B), polyphagia (C), and hyperkalemia (D) are not typical.
A mother calls the clinic to report that her otherwise healthy newborn has a rash on his forehead and face. The nurse should tell the mother:
- A. To use a mild soap when washing the newborn's face
- B. That many newborns have a rash that will go away by one month of life
- C. That the rash indicates illness and she needs to bring the newborn in immediately
- D. To check for signs of illness among family members
Correct Answer: B
Rationale: Many newborns develop erythema toxicum or milia benign rashes that resolve within a month. This is the most likely explanation for a healthy newborn’s facial rash. Immediate evaluation or family illness checks are unnecessary unless other symptoms are present.
The nurse is caring for a client with a history of cirrhosis. The nurse should give priority to:
- A. Monitoring for bleeding
- B. Administering diuretics
- C. Monitoring blood glucose
- D. Assessing for infection
Correct Answer: A
Rationale: Cirrhosis impairs clotting factor production, increasing bleeding risk, so monitoring for bleeding is a priority.