Nokea
A breastfeeding mother complains of cramping. Which is the main cause of the client's afterpains?
- A. Infection of the suture line
- B. Constipation and bloating
- C. Contractions of the uterus
- D. Trauma during delivery
Correct Answer: C
Rationale: The correct answer is C: Contractions of the uterus. After giving birth, the uterus continues to contract to reduce in size, which can cause cramping or afterpains. This is a normal process known as involution. Infection of the suture line (A) would present with other symptoms like redness, swelling, and warmth. Constipation and bloating (B) may cause discomfort but are not directly related to afterpains. Trauma during delivery (D) could lead to pain but is not the main cause of afterpains in a breastfeeding mother.
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When planning for the care of an infant experiencing neonatal abstinence syndrome, which nursing assessment is most important?
- A. The mother's ability to provide a safe environment
- B. The extent of addiction of the mother
- C. The mother's ability to obtain treatment
- D. The severity of the infant's withdrawal
Correct Answer: A
Rationale: The correct answer is A: The mother's ability to provide a safe environment. This is crucial because infants with neonatal abstinence syndrome require a stable and safe environment for optimal care and recovery. Assessing the mother's ability to provide this environment helps ensure the infant's safety and well-being. Choice B is incorrect because the extent of the mother's addiction, while important, does not directly impact the immediate care of the infant. Choice C is incorrect as the focus should be on the current situation and care of the infant rather than the mother obtaining treatment. Choice D is incorrect as the severity of the infant's withdrawal, though important, is not the most critical assessment in planning care.
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 preparing to administer an intramuscular (IM) injection to a 2-month-old infant. Which of the following is the preferred injection site?
- A. "Vastus lateralis"'
- B. "Deltoid muscle"'
- C. "Ventrogluteal site"'
- D. NA
Correct Answer: A
Rationale: The correct answer is A: "Vastus lateralis." For infants, the vastus lateralis muscle in the thigh is the preferred site for IM injections due to its large size, well-developed muscle mass, and minimal major blood vessels and nerves. This reduces the risk of injury and ensures proper medication absorption. The deltoid muscle (choice B) is typically used for older children and adults, not infants. The ventrogluteal site (choice C) is more commonly used for adults and older children as well. Not Applicable (choice D) does not provide any relevant information.
A 38 week gestation newborn weighs 4020 grams, is sluggish, and has limp muscle tone. The baby experienced a broken clavicle during delivery. Based on this information, which can the nurse conclude about the baby?
- A. Neonatal abstinence symptoms
- B. Large for gestational age
- C. Congenital cardiac defect
- D. Respiratory depression
Correct Answer: B
Rationale: The correct answer is B: Large for gestational age. A newborn weighing 4020 grams at 38 weeks is considered large for gestational age. The sluggishness and limp muscle tone can be attributed to the baby's size, which can make movement more challenging. The broken clavicle could have occurred during delivery due to the baby's size and the forces involved. Neonatal abstinence symptoms (choice A) typically present with irritability, tremors, and poor feeding, not sluggishness. Congenital cardiac defects (choice C) usually manifest with cyanosis, tachypnea, and poor feeding. Respiratory depression (choice D) is characterized by poor respiratory effort, not sluggishness and limp muscle tone.
A women in her first trimester contracts rubella. How is the fetus likely to be affected?
- A. Reproductive and urinary defects
- B. Heart defects and cataracts
- C. Spinal cord and skeletal defects
- D. Polydactyly and club feet
Correct Answer: B
Rationale: The correct answer is B: Heart defects and cataracts. Rubella infection during the first trimester can lead to congenital rubella syndrome, causing heart defects and cataracts in the fetus. Rubella affects organ development during this critical period. Choice A is incorrect as rubella does not typically cause reproductive and urinary defects. Choice C is incorrect because rubella does not usually result in spinal cord and skeletal defects. Choice D is incorrect as polydactyly and club feet are not typical manifestations of rubella infection during pregnancy.