Nokea
A healthcare professional is preparing to assess a 2-week-old newborn. Which of the following actions should the professional plan to take?
- A. Obtain the newborn's body temperature using a tympanic thermometer.
- B. FACES pain scale.
- C. Auscultate the newborn's apical pulse for 60 seconds.
- D. Measure the newborn's head circumference over the eyebrows and below the occipital prominence.
Correct Answer: C
Rationale: Assessing the apical pulse in newborns is important to evaluate their cardiac function. The normal heart rate for a newborn is typically between 100-160 beats per minute. Auscultating the apical pulse for a full 60 seconds allows for an accurate assessment of the newborn's heart rate. This is a crucial component of the newborn assessment to ensure the baby's cardiovascular system is functioning within the expected range.
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A nurse manager is developing a protocol for an urgent care clinic that often cares for clients who do not speak the same language as clinical staff. Which of the following instructions should the nurse include?
- A. Use a professional interpreter service
- B. Nurse to interpret
- C. Provide translation services for a nominal fee to clients
- D. Evaluate the clients' understanding at regular intervals
Correct Answer: B
Rationale: In situations where there is a language barrier between healthcare providers and patients, it is essential to ensure accurate communication. Using professional interpreter services is the most appropriate choice to ensure clear and precise communication. Relying on the client's children for interpretation may not guarantee accurate or confidential communication. Asking the nurse to interpret can lead to miscommunication or misunderstanding of important medical information. Providing translation services for a nominal fee to clients may not always be feasible or culturally appropriate. Regularly evaluating the client's understanding helps ensure that information is effectively communicated and comprehended.
A client in labor is receiving oxytocin. Which of the following findings indicates that the nurse should increase the rate of infusion?
- A. Urine output of 20 ml/hr.
- B. Montevideo units constantly at 300 mm Hg.
- C. FHR pattern showing absent variability.
- D. Contractions occurring every 5 minutes and lasting 30 seconds.
Correct Answer: B
Rationale: Montevideo units measure the strength and frequency of contractions during labor. A consistent Montevideo units reading of 300 mm Hg or higher is indicative of effective uterine contractions. In this scenario, an increase in the rate of oxytocin infusion may be warranted to further augment contractions and promote progress in labor. The other options, such as low urine output, absent variability in fetal heart rate, and short contractions, do not directly correlate with the need for an increase in oxytocin infusion rate.
A client is being assessed by a nurse who is 30 minutes postoperative following an arterial thrombectomy. Which of the following findings should the nurse report?
- A. Chest pain
- B. Muscle spasms
- C. Cool, moist skin
- D. Incisional pain
Correct Answer: A
Rationale: Chest pain is a critical finding postoperatively, especially after an arterial thrombectomy, as it could indicate complications like myocardial infarction or pulmonary embolism. It requires immediate attention and further evaluation. Muscle spasms, cool moist skin, and incisional pain are important to assess but not as urgent as chest pain in this scenario.
When teaching about electrical fire prevention at a community health fair, which of the following information should be included?
- A. Use three-pronged grounded plugs.
- B. Cover extension cords with a rug.
- C. Check for tingling sensations around the cord to ensure electricity is working.
- D. Remove the plug from the socket by pulling the plug, not the cord.
Correct Answer: A
Rationale: The correct answer is to use three-pronged grounded plugs because they are safer and reduce the risk of electrical fires. Option B is incorrect as covering extension cords with a rug can pose a fire hazard. Option C is incorrect; tingling sensations around a cord indicate an electrical issue, not proper functioning. Option D is unsafe; plugs should be removed from the socket by pulling the plug, not the cord, to prevent damage and reduce the risk of electrical hazards.
A client who is at 38 weeks gestation, is in active labor, and has ruptured membranes is being cared for by a nurse. What action should the nurse take?
- A. Insert an indwelling urinary catheter
- B. Apply fetal heart rate monitor
- C. Initiate fundal massage
- D. Initiate an oxytocin IV infusion
Correct Answer: B
Rationale: When caring for a client in active labor with ruptured membranes, the priority action for the nurse is to apply a fetal heart rate monitor. This helps monitor the well-being of the fetus during labor and delivery, enabling timely interventions if any fetal distress is detected. Inserting an indwelling urinary catheter may be required in some cases, but it is not the priority in the given scenario. Fundal massage is typically done after delivery to help the uterus contract and prevent postpartum hemorrhage. Initiating an oxytocin IV infusion may be indicated to augment labor, but it is not the initial action needed in this situation.