Nokea
A client delivered vaginally six hours ago. Which assessment finding can be interpreted as normal?
- A. Temperature 100.0 degrees F
- B. Blood pressure 140/90
- C. Respirations 10
- D. Pulse 90
Correct Answer: A
Rationale: The correct answer is A: Temperature 100.0 degrees F. This finding can be interpreted as normal because a slight increase in body temperature after childbirth is expected due to the physiological changes during labor. A temperature of 100.0 degrees F is within the normal range for postpartum women.
Rationale for why the other choices are incorrect:
B: Blood pressure 140/90 - This blood pressure reading is slightly elevated and may indicate hypertension, which would not be considered normal postpartum.
C: Respirations 10 - A respiratory rate of 10 is abnormally low and could indicate respiratory distress rather than normal postpartum recovery.
D: Pulse 90 - A pulse rate of 90 may be within normal limits, but it is not as indicative of normal postpartum recovery as a slightly elevated temperature would be.
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A 1-year-old receives routine health maintenance care at the pediatric clinic. The child receives an MMR immunization. The mother asks the nurse, 'When will my child get the next dose of MMR vaccine?' Which is the correct response by the nurse?
- A. In six months with the next DPT
- B. No further vaccination needed
- C. With the Hepatitis B series
- D. After the child is 10 years of age
Correct Answer: D
Rationale: A second MMR, often called a booster, will be needed when the child enters middle school at age eleven or twelve years of age. This ensures full immunity from the diseases covered by the MMR vaccine.
A nurse is talking to the parents of a 3-year-old child about water safety precautions. Which of the following statements made by the parents indicates a need for clarification?
- A. We keep the toilet seat down at all times.
- B. We don't answer the phone during bath time.
- C. We empty all buckets filled with water.
- D. We have our child in swimming lessons.
Correct Answer: D
Rationale: The correct answer is D because enrolling a 3-year-old child in swimming lessons does not necessarily prevent drowning incidents. It is crucial for parents to understand that even with swimming lessons, active supervision around water is essential to prevent accidents. Keeping the toilet seat down (A), avoiding distractions during bath time (B), and emptying buckets filled with water (C) are all important water safety precautions to prevent drowning incidents. Swimming lessons are beneficial, but they should not replace vigilant supervision.
During active labor, after a sudden slowing of the fetal heart rate, the nurse assesses the woman's perineum and observes a prolapsed cord. Which nursing action is most appropriate?
- A. Hold the presenting part away from the cord
- B. Insert a scalp electrode for an internal fetal monitor
- C. Place the client in reverse Trendelenburg position
- D. Cover the cord with a dry,sterile gauze
Correct Answer: A
Rationale: The correct answer is A: Hold the presenting part away from the cord. This action helps relieve pressure on the cord, preventing further compromise of blood flow to the fetus. It is crucial to maintain fetal perfusion. Choice B (Insert a scalp electrode) and D (Cover the cord with gauze) are not appropriate as they do not address the immediate risk of cord compression. Choice C (Reverse Trendelenburg) may worsen the prolapse by shifting the presenting part higher.
Which nursing instruction should be given to the breastfeeding mother regarding care of the breasts after discharge?
- A. Engorgement occurs on about the third or fourth postpartum day and is a result of the breast milk formation. The primary way to relieve engorgement is by pumping or longer nursing. Giving a bottle of formula will compound the problem because the baby will not be hungry and will not empty the breasts well.
- B. Applying lotion to the nipples is not effective for keeping them soft. Excessive amounts of lotion may harbor microorganisms.
- C. In order to stimulate adequate milk production, the breasts should be pumped if the infant is not sucking or eating well, or if the breasts are not fully emptied.
- D. Using soap on the breasts dries the nipples and can cause cracking. The baby should be given a bottle of formula if engorgement occurs.
Correct Answer: C
Rationale: The correct answer is C. It is important to stimulate adequate milk production by pumping if the infant is not sucking or eating well, or if the breasts are not fully emptied. This helps maintain milk supply and prevents engorgement. Option A is incorrect as giving a bottle of formula does not effectively relieve engorgement and can lead to decreased milk production. Option B is incorrect as applying lotion to the nipples is not necessary and may introduce harmful microorganisms. Option D is incorrect as using soap can dry the nipples and lead to cracking, and giving formula is not the recommended solution for engorgement.
Which method of temperature regulation would safely and effectively prevent cold stress in a newly delivered infant?
- A. Wrap the baby loosely with a blanket.
- B. Be sure the baby's feet are covered.
- C. Cover the baby's head with a hat.
- D. Position the baby on a heating pad.
Correct Answer: C
Rationale: The correct answer is C: Cover the baby's head with a hat. Infants lose a significant amount of heat through their heads, so covering the head with a hat helps prevent heat loss and cold stress. Option A does not provide enough insulation to prevent cold stress. Option B only addresses the feet, while the head is a major heat loss area. Option D poses a risk of overheating and burns.