Nokea
A client who is postpartum and has thrombophlebitis requires nursing interventions. Which of the following nursing interventions should the nurse recommend?
- A. Apply cold compresses to the affected extremity
- B. Massage the affected extremity
- C. Allow the client to ambulate
- D. Measure leg circumferences
Correct Answer: D
Rationale: The correct answer is D - Measure leg circumferences. This is important in assessing for changes in swelling, which can indicate worsening thrombophlebitis. Monitoring leg circumferences helps in early detection of complications like deep vein thrombosis. Applying cold compresses (A) can worsen vasoconstriction, massage (B) can dislodge clots, and allowing ambulation (C) can increase the risk of clot migration.
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A newborn who was born at 38 weeks of gestation, weighs 3,200 g, and is in the 60th percentile for weight should be classified as which of the following?
- A. Low birth weight
- B. Appropriate for gestational age
- C. Small for gestational age
- D. Large for gestational age
Correct Answer: B
Rationale: The correct answer is B: Appropriate for gestational age. A newborn is considered appropriate for gestational age when their weight falls within the 10th to 90th percentiles for their gestational age. In this case, the newborn is in the 60th percentile for weight, indicating that the weight is appropriate for the gestational age of 38 weeks.
Choice A: Low birth weight is incorrect because a newborn is classified as low birth weight when their weight is below 2,500 g regardless of gestational age.
Choice C: Small for gestational age is incorrect because a newborn is classified as small for gestational age when their weight is below the 10th percentile for their gestational age.
Choice D: Large for gestational age is incorrect because a newborn is classified as large for gestational age when their weight is above the 90th percentile for their gestational age.
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 healthcare professional is discussing risk factors for urinary tract infections with a newly licensed nurse. Which of the following conditions should the healthcare professional include in the teaching? (Select all that apply)
- A. Epidural anesthesia
- B. Urinary bladder catheterization
- C. Frequent pelvic examinations
- D. All of the Above
Correct Answer: D
Rationale: The correct answer is D (All of the Above). Epidural anesthesia can increase the risk of urinary retention leading to UTIs. Urinary bladder catheterization can introduce pathogens into the urinary tract. Frequent pelvic examinations can disrupt the natural flora and introduce bacteria. Therefore, all the conditions listed can contribute to an increased risk of urinary tract infections. The other choices (A, B, C) are incorrect because each of them individually presents a risk factor for UTIs, and selecting only one or two choices would not encompass the full range of risk factors that the healthcare professional should include in the teaching.
A healthcare professional is preparing to administer prophylactic eye ointment to a newborn to prevent ophthalmia neonatorum. Which of the following medications should the healthcare professional anticipate administering?
- A. Ofloxacin
- B. Nystatin
- C. Erythromycin
- D. Ceftriaxone
Correct Answer: C
Rationale: The correct answer is C: Erythromycin. Erythromycin is the standard treatment for preventing ophthalmia neonatorum, a condition caused by Neisseria gonorrhoeae or Chlamydia trachomatis. It is a broad-spectrum antibiotic that effectively prevents bacterial infections in newborns. Ofloxacin (A) is a fluoroquinolone antibiotic not typically used in newborns. Nystatin (B) is an antifungal medication used for treating fungal infections, not bacterial infections like ophthalmia neonatorum. Ceftriaxone (D) is a cephalosporin antibiotic used for various bacterial infections, but it is not the first-line treatment for preventing ophthalmia neonatorum.
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.