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A healthcare professional is preparing to measure an infant's temperature. Which of the following actions should the healthcare professional take?
- A. Place the tip of the thermometer under the center of the infant's axilla
- B. Pull the pinna of the infant's ear forward before inserting the probe
- C. Insert the probe 3.8 cm (1.5in) into the infant's rectum
- D. Insert the thermometer in front of the infant's tongue
Correct Answer: A
Rationale: When measuring an infant's temperature, the most appropriate and non-invasive method is to place the tip of the thermometer under the center of the infant's axilla (armpit). This method is safe, quick, and comfortable for the infant. Inserting the probe into the rectum is invasive and not recommended for routine temperature measurement in infants. Inserting the thermometer in front of the infant's tongue is not a reliable method for measuring temperature. Pulling the pinna of the ear forward is a technique used for adults, not infants.
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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 with fibromyalgia requests pain medication. Which of the following medications should the nurse administer?
- A. Pregabalin
- B. Lorazepam
- C. Colchicine
- D. Codeine
Correct Answer: A
Rationale: Pregabalin is commonly used to manage pain associated with fibromyalgia. It works by reducing the number of pain signals sent out by damaged nerves. Lorazepam is a benzodiazepine used for anxiety, not pain management. Colchicine is primarily used for gout treatment, and codeine, while an analgesic, is not typically the first-line choice for fibromyalgia pain due to its potential for side effects and misuse.
A client has chronic pancreatitis. Which of the following dietary recommendations should be made?
- A. Coffee with creamer
- B. Lettuce with sliced avocados
- C. Broiled skinless chicken breast with brown rice
- D. None of the above
Correct Answer: C
Rationale: Chronic pancreatitis requires a low-fat diet to reduce stress on the pancreas. Broiled skinless chicken breast with brown rice is a suitable option as it is low in fat. Coffee with creamer and lettuce with sliced avocados are not recommended for individuals with chronic pancreatitis due to their fat content. Choosing options high in fat can exacerbate symptoms and increase the workload on the pancreas, worsening the condition.
When caring for a client who speaks a language different from their own, what action should the nurse take?
- A. Request an interpreter of a different sex from the client.
- B. Request a family member or friend to interpret information for the client.
- C. Direct attention toward the interpreter when speaking to the client.
- D. Review the facility policy about the use of an interpreter.
Correct Answer: D
Rationale: When caring for a client who speaks a different language, it is essential for the nurse to review the facility policy about the use of an interpreter. Using a professional interpreter ensures accurate communication and protects the client's confidentiality. Requesting an interpreter of a specific sex or relying on family members or friends can lead to miscommunication or breaches of confidentiality. Directing attention towards the interpreter helps facilitate communication but does not address the need for a professional interpreter as per facility policy.
A public health nurse is managing several projects for the community. Which of the following interventions should the nurse identify as a primary prevention strategy?
- A. Teaching parenting skills to expectant mothers and their partners.
- B. Conducting mental health screenings at the local community center
- C. Referring clients with obesity to community exercise programs
- D. Providing crisis intervention through a mobile counseling unit
Correct Answer: A
Rationale: The correct answer is teaching parenting skills to expectant mothers and their partners. This intervention is a primary prevention strategy aimed at educating individuals before a problem or condition develops. By teaching parenting skills, the nurse is promoting healthy behaviors and relationships, which can prevent future issues. The other options involve secondary or tertiary prevention strategies by identifying and treating existing conditions or providing interventions after a problem has occurred.