Nokea
A client who is 18 weeks’ gestation has been diagnosed with a hydatiform mole (gestational trophoblastic disease). In addition to vaginal loss, which of the following signs/symptoms would the nurse expect to see?
- A. Hyperemesis and hypertension.
- B. Diarrhea and hyperthermia.
- C. Polycythemia.
- D. Polydipsia.
Correct Answer: A
Rationale: Hyperemesis and hypertension are common symptoms of a hydatiform mole due to the excessive production of hCG.
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A couple has decided not to circumcise their son. Based on this decision, which of the following instructions should the nurse include in the parent teaching?
- A. The couple should check their son’s temperature every evening because he will be high risk for urinary tract infections.
- B. The couple should fully retract the foreskin to assess for the presence of exudate every morning.
- C. The pediatrician will observe the baby void during each well-baby examination to assess for a phimosis.
- D. The prepuce should be cleansed with soap and water every day during the baby’s sponge bath.
Correct Answer: D
Rationale: Proper hygiene, including cleaning the uncircumcised penis with soap and water, helps prevent infections.
A nurse is completing a minimum data set. Which area is the nurse working?
- A. Nursing center
- B. Psychiatric facility
- C. Rehabilitation center
- D. Adult day care center
Correct Answer: A
Rationale: Nurses who work in a nursing center (nursing home or nursing facility) are required to complete a minimum data set on each patient. Minimum data set is not needed for psychiatric, rehabilitation, or adult day care centers.
A 42-week-gestation neonate is being assessed. Which of the following findings would the nurse expect to see?
- A. Folded and flat pinnae.
- B. Smooth plantar surfaces.
- C. Loose and peeling skin.
- D. Short pliable fingernails.
Correct Answer: C
Rationale: Post-term neonates often have loose and peeling skin due to prolonged exposure to amniotic fluid.
A nurse notes that a baby is lying in a crib in the tonic neck position. In which of the following positions is the baby lying?
- A. One of the baby's arms and one of its legs are extended to the same side the baby's head is facing.
- B. When the baby faces straight ahead, the baby's head tilts toward one side.
- C. Both the baby's back and head are sharply arched backward and resist being moved to midline.
- D. When the baby lies prone, the baby's body arches to one side.
Correct Answer: A
Rationale: The tonic neck reflex, or fencer's position, involves the baby's arm and leg on one side extending while the opposite arm and leg flex.
Which technique would provide the best pain relief for a pregnant woman with an occiput posterior position?
- A. Neuromuscular disassociation
- B. Effleurage
- C. Psychoprophylaxis
- D. Sacral pressure
Correct Answer: D
Rationale: The correct answer is D: Sacral pressure. This technique involves applying pressure to the sacrum to alleviate back pain associated with an occiput posterior position. The pressure helps relieve tension and discomfort in the lower back, providing effective pain relief for the pregnant woman.
A: Neuromuscular disassociation is not specific to addressing the pain associated with the occiput posterior position in pregnancy.
B: Effleurage is a gentle massage technique that may provide some relaxation but may not be as effective as sacral pressure for pain relief in this specific scenario.
C: Psychoprophylaxis is a method of preparing for childbirth through education and relaxation techniques, but it may not directly target the pain caused by the occiput posterior position.
In summary, sacral pressure is the most appropriate technique as it directly addresses the specific pain associated with the occiput posterior position in pregnancy, unlike the other choices.