Nokea
A client is in the latent stage of labor. Which nursing intervention is most appropriate?
- A. Encourage the client to walk in the hall until membranes rupture
- B. Instruct the client to place her head on her chest and push with the contraction
- C. Teach the client to use the 'pant-blow' method of breathing
- D. Advise the client to eat a light meal consisting of carbohydrates
Correct Answer: A
Rationale: The correct answer is A because encouraging the client to walk in the hall can help progress labor by promoting movement and gravity, potentially aiding in cervical dilation and descent of the fetus. Walking may also provide comfort and distraction from labor discomfort. Choices B and C are incorrect as they are not appropriate actions during the latent stage of labor and can be harmful. Choice D is incorrect because it is not recommended to eat a meal during labor due to the risk of aspiration if anesthesia is needed.
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An assistive personnel (AP) is caring for a child diagnosed with leukemia and undergoing chemotherapy.
- A. "The AP offers a soft toothbrush for oral care."'
- B. "The AP applies a soft cotton cap to the child's head."'
- C. "The AP maintains a restriction of all visitors and health personnel with infections."'
- D. "The AP prepares to take a rectal temperature."'
Correct Answer: D
Rationale: Correct answer: D. "The AP prepares to take a rectal temperature."
Rationale: Taking a rectal temperature is crucial in monitoring the child's health during chemotherapy, as it provides a more accurate reading of the body's core temperature. Chemotherapy can suppress the immune system, increasing the risk of infections, so monitoring for fever is essential. Additionally, rectal temperature is the most accurate method for infants and young children.
Option A: Offering a soft toothbrush for oral care is important, but it is not the most critical action to take in this scenario.
Option B: Applying a soft cotton cap to the child's head may provide comfort but is not as essential as monitoring the child's temperature.
Option C: Maintaining a restriction of visitors and health personnel with infections is important for infection control, but this does not directly address the immediate need of monitoring the child's temperature.
In summary, taking a rectal temperature is the most critical action to ensure early detection of fever and prompt intervention
Which information is most important for the nurse to gather when a client is admitted to the unit in labor?
- A. Name of the support person
- B. Medical problems or complications
- C. Fluid preferences
- D. Amount of weight gained during the pregnancy
Correct Answer: B
Rationale: The correct answer is B: Medical problems or complications. This information is crucial for assessing the client's risk status and determining appropriate care during labor. Knowing the medical history helps identify potential complications that may arise and allows the nurse to plan for necessary interventions. Gathering information on the support person (choice A) is important but not as critical as the client's medical history. Fluid preferences (choice C) and weight gained during pregnancy (choice D) are relevant but do not directly impact the immediate care needed during labor. Without additional choices provided, it is evident that medical problems or complications (choice B) takes precedence in ensuring the safety and well-being of both the client and the baby.
A nurse is assessing a newborn 12 hr after birth. Which of the following manifestations should the nurse report to the provider?
- A. Acrocyanosis
- B. Transient strabismus
- C. Jaundice
- D. Caput succedaneum
Correct Answer: C
Rationale: The correct answer is C: Jaundice. Jaundice in a newborn 12 hours after birth could indicate physiological jaundice, but it should still be reported to the provider for further evaluation. Jaundice can be a sign of hyperbilirubinemia, which if left untreated, can lead to complications like kernicterus. Acrocyanosis (A), transient strabismus (B), and caput succedaneum (D) are common and expected findings in newborns and do not typically require immediate reporting unless they are severe or persistent.
A 6-year-old child is brought to the emergency department after falling down the outdoor steps. The parent's account of the incident appears different than the neighbor's account of the incident. Upon questioning the child, the nurse should recognize which of the following as usual pattern of behavior exhibited by an abused child?
- A. The child refuses to answer questions.
- B. The child repeats the same story as the parent.
- C. The child will fabricate an obviously false story.
- D. The child tells what really happened at the time.
Correct Answer: B
Rationale: Abused children often repeat their parents' stories to avoid implicating them.
What is the main cause of mastitis in the postpartum client?
- A. Poor breastfeeding technique
- B. Inadequate hand washing
- C. Systemic maternal infection
- D. Prolonged nursing
Correct Answer: A
Rationale: The correct answer is A: Poor breastfeeding technique. Mastitis in postpartum clients is commonly caused by milk stasis due to inadequate milk removal, which can result from poor breastfeeding technique such as improper latch or infrequent feedings. This leads to inflammation and infection. Inadequate hand washing (B) is important for preventing infection but not the main cause of mastitis. Systemic maternal infection (C) may contribute but is not the primary cause. Prolonged nursing (D) can actually help prevent mastitis by promoting milk flow.