Nokea
A client has a new prescription for chlamydia. Which of the following statements should the nurse provide?
- A. This infection is treated with one dose of azithromycin.
- B. If your sexual partner has no symptoms, no medication is needed.
- C. You should avoid sexual relations for 3 days.
- D. You need to return in 6 months for retesting.
Correct Answer: A
Rationale: The correct answer is A because chlamydia is commonly treated with a single dose of azithromycin to ensure complete eradication of the infection. This antibiotic is highly effective against chlamydia. Option B is incorrect because both partners need treatment regardless of symptoms. Option C is incorrect as sexual abstinence for 7 days is recommended post-treatment. Option D is incorrect as retesting should be done after 3 months, not 6 months.
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When calculating the Apgar score of a newborn at 1 minute after delivery, which of the following findings would result in a score of 6?
- A. 4
- B. 5
- C. 6
- D. 7
Correct Answer: C
Rationale: The Apgar score assesses the newborn's overall condition at birth based on five criteria: heart rate, respiratory effort, muscle tone, reflex irritability, and color. A score of 6 at 1 minute indicates moderate difficulty in transitioning to extrauterine life. For a score of 6, the baby may have a heart rate below 100 bpm, weak respiratory effort, some muscle tone, grimacing reflex irritability, and a body with bluish extremities but normal body color. Choice C aligns with these criteria. Choices A, B, and D do not meet the requirements for a score of 6 as they represent either too low or too high values in one or more criteria, resulting in a different Apgar score.
A client in the delivery room just delivered a newborn, and the nurse is planning to promote parent-infant bonding. What should the nurse prioritize?
- A. Encourage the parents to touch and explore the newborn's features
- B. Limit noise and interruptions in the delivery room
- C. Place the newborn at the client's breast
- D. Position the newborn skin-to-skin on the client's chest
Correct Answer: D
Rationale: The correct answer is D: Position the newborn skin-to-skin on the client's chest. This promotes bonding through touch, warmth, and smell, stimulating the release of oxytocin in both the parent and the infant. Skin-to-skin contact enhances attachment, regulates the newborn's temperature and breathing, and supports breastfeeding initiation.
A: Encouraging parents to touch and explore the newborn's features is important but not as crucial as immediate skin-to-skin contact for bonding and physiological benefits.
B: Limiting noise and interruptions can create a calm environment but does not directly promote bonding like skin-to-skin contact.
C: Placing the newborn at the client's breast is beneficial for breastfeeding initiation but may not provide the same level of closeness and comfort as skin-to-skin contact.
A newborn is noted to have secretions bubbling out of the nose and mouth after delivery. What is the nurse's priority action?
- A. Suction the nose with a bulb syringe.
- B. Suction the mouth with a bulb syringe.
- C. Use a suction catheter with low negative pressure.
- D. Turn the newborn on their side.
Correct Answer: B
Rationale: The correct answer is B: Suction the mouth with a bulb syringe. This is the priority action because secretions in the mouth can obstruct the airway and lead to respiratory distress. Suctioning the mouth first helps clear the airway effectively. Suctioning the nose with a bulb syringe (choice A) may not address the immediate risk of airway obstruction. Using a suction catheter with low negative pressure (choice C) can be too strong for a newborn. Turning the newborn on their side (choice D) may not effectively address the airway obstruction from secretions in the mouth.
A client who is postpartum has a slightly boggy and displaced fundus to the right. Which of the following actions should the nurse take based on these findings?
- A. Encourage the client to perform Kegel exercises.
- B. Encourage the client to move to the left lateral position.
- C. Ask the client to rate her pain.
- D. Assist the client to the bathroom to void.
Correct Answer: D
Rationale: The correct answer is D: Assist the client to the bathroom to void. A boggy and displaced fundus to the right in a postpartum client suggests a full bladder, which can displace the uterus. Voiding helps the uterus contract back to its normal position, reducing the risk of postpartum hemorrhage. Encouraging Kegel exercises (A) is not appropriate in this situation. Moving to the left lateral position (B) may provide temporary relief but does not address the underlying issue. Asking the client to rate her pain (C) is not relevant to the management of a displaced fundus.
A nurse on a labor unit is admitting a client who reports painful contractions. The nurse determines that the contractions have a duration of 1 minute and a frequency of 3 minutes. The nurse obtains the following vital signs: fetal heart rate 130/min, maternal heart rate 128/min, and maternal blood pressure 92/54 mm Hg. Which of the following is the priority action for the nurse to take?
- A. Notify the provider of the findings.
- B. Position the client with one hip elevated.
- C. Ask the client if she needs pain medication.
- D. Have the client void.
Correct Answer: B
Rationale: The correct answer is B: Position the client with one hip elevated. This is the priority action because the client's contractions are frequent and of significant duration, indicating active labor. Elevating one hip can help improve fetal oxygenation and blood flow during contractions. It can also help optimize fetal positioning for a smoother labor process.
Choice A: Notifying the provider is important but not the priority at this moment. The nurse should first address immediate client needs.
Choice C: Asking about pain medication is important, but managing the client's positioning for labor progress takes precedence.
Choice D: Having the client void is a routine step in labor management but is not the priority action in this scenario.