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 client at 28 weeks of gestation received terbutaline. Which of the following findings should the nurse expect?
- A. Fetal heart rate 100/min
- B. Weakened uterine contractions
- C. Enhanced production of fetal lung surfactant
- D. Maternal blood glucose 63 mg/dL
Correct Answer: B
Rationale: The correct answer is B: Weakened uterine contractions. Terbutaline is a tocolytic medication that inhibits uterine contractions. This helps prevent preterm labor. At 28 weeks of gestation, the nurse would expect terbutaline to weaken uterine contractions, rather than increase fetal heart rate (choice A), enhance fetal lung surfactant production (choice C), or lower maternal blood glucose levels (choice D). Weakening of uterine contractions is the expected therapeutic effect of terbutaline in this scenario to delay preterm labor.
A client who is 2 days postpartum reports that their 4-year-old son, who was previously toilet trained, is now wetting himself frequently. Which of the following statements should the nurse provide to the client?
- A. Your son may not have been ready for toilet training and should wear training pants.
- B. Your son is displaying an adverse sibling response.
- C. Your son may benefit from counseling.
- D. Consider enrolling your son in preschool to address the behavior.
Correct Answer: B
Rationale: The correct answer is B: Your son is displaying an adverse sibling response. This is the correct answer because the 4-year-old's regression in toilet training is likely a response to the recent birth of a new sibling. This behavior is common as the older child may feel jealous or neglected, leading to regression. Providing this statement will help the client understand the underlying cause of the behavior and address it appropriately.
Incorrect choices:
A: This choice suggests the child was not ready for toilet training, which is not the primary issue here.
C: Counseling may be beneficial in some cases but is not the first-line intervention for this situation.
D: Enrolling in preschool may not directly address the underlying cause of the behavior, which is related to the new sibling.
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 nurse concludes that the parent of a newborn is not showing positive indications of parent-infant bonding. The parent appears very anxious and nervous when asked to bring the newborn to the other parent. Which of the following actions should the nurse use to promote parent-infant bonding?
- A. Hand the parent the newborn and suggest that they change the diaper.
- B. Ask the parent why they are so anxious and nervous.
- C. Tell the parent that they will grow accustomed to the newborn.
- D. Provide reinforcement about infant care when the parent is present.
Correct Answer: D
Rationale: The correct answer is D because providing reinforcement about infant care when the parent is present can help build the parent's confidence and competence in caring for the newborn, which can enhance parent-infant bonding. By offering support and guidance during interactions with the newborn, the parent can feel more comfortable and connected to the baby.
A: Handing the parent the newborn and suggesting they change the diaper may increase their anxiety and not address the underlying issue of bonding.
B: Asking the parent why they are anxious and nervous is important but may not directly promote bonding without providing concrete support.
C: Telling the parent they will grow accustomed to the newborn does not actively support bonding or address the parent's current concerns.
In summary, choice D is the best option as it provides practical assistance and positive reinforcement to help the parent feel more confident in caring for the newborn, ultimately fostering parent-infant bonding.
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.