Nokea
A father watching the admission of his newborn to the nursery notices that eye ointment is placed in the infant's eyes. He asks the nurse what is the purpose of the ointment. Which response by the nurse will best explain the purpose for administering the ointment?
- A. The ointment will prevent a herpes infection.'
- B. The ointment will clear the infant's vision.'
- C. The ointment will dilate the pupil so the red reflex can be visualized.'
- D. The ointment will prevent eye infections.'
Correct Answer: D
Rationale: Erythromycin ointment prevents ophthalmia neonatorum from gonorrhea or chlamydia, reducing blindness risk.
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A newborn is delivered by cesarean section to a mother who is HIV-positive. The mother received antiretroviral therapy during pregnancy. Which intervention should the nurse implement?
- A. Encourage breastfeeding every 2 to 3 hours.
- B. Administer antibiotics for 7 to 10 days.
- C. Give zidovudine 6 to 12 hours after birth.
- D. Delay the initial bath for 1 to 2 days.
Correct Answer: C
Rationale: Zidovudine within 6-12 hours reduces perinatal HIV transmission risk in newborns of HIV-positive mothers.
An 8-year-old girl with precocious sexual development is being treated medically with injections of luteinizing hormone-releasing hormone (LHRH) to regulate the pituitary gland. Which statement by the parents indicates that they understand the treatment?
- A. We should be sure to start our daughter on birth control pills.'
- B. Sexual maturity differences between my daughter and her peers will disappear within a few years.'
- C. Our daughter will be on this hormone treatment the rest of her life.'
- D. We should encourage her to dress in clothing that suits her sexual maturity level.'
Correct Answer: B
Rationale: LHRH therapy delays premature puberty, allowing physical maturity to align with peers over time, with treatment stopping at an appropriate age.
Nurses' Notes
Orders
The client is a 4-month-old female with a history of gastroesophageal reflux (GERD). Client had fundoplication surgery and will be hospitalized for several days of recovery.
Which other assessment data would the nurse want to collect before implementing pain management strategies? Select all that apply.
- A. Blood type
- B. Parents religious affiliation
- C. Blood pressure
- D. Level of consciousness
- E. Hearing acuity
- F. Heart rate
- G. Deep tendon reflexes
Correct Answer: C,D,F
Rationale: Blood pressure, level of consciousness, and heart rate assess pain intensity and guide safe pain management. Blood type, religion, hearing, and reflexes are not directly relevant.
The nurse is giving instructions to the mother of a 10-year-old boy who is newly diagnosed with type 1 diabetes mellitus (DM). When attempting to teach the mother how to administer subcutaneous insulin injections to the child, the mother tells the nurse that she is afraid of needles and cannot perform the procedure. Which intervention should the nurse implement?
- A. Determine if the child can administer the insulin.
- B. Ask if the father can help with the injections.
- C. Assess the mother's parenting skills.
- D. Encourage the mother to handle the needles.
Correct Answer: D
Rationale: Gradual exposure to needles through practice builds the mother's confidence, ensuring effective insulin administration for diabetes management.
The healthcare provider prescribes magnesium sulfate 6 grams IV to be infused over 20 minutes for client with preterm labor. The IV bag contains 'Magnesium sulfate 20 grams in dextrose 5% in water 500 mL.' How many mL/hour should the nurse set the infusion pump?
- A. 450 mL/hour
Correct Answer: A
Rationale: For 6 grams in 20 minutes, 150 mL (6 ÷ 0.04 g/mL) is needed. Infusion rate is 150 mL ÷ 20 min × 60 = 450 mL/hour.