Nokea
A labor and delivery nurse suspects that a client is in the transition stage of labor. Which information supports this conclusion? The client is:
- A. walking around the unit and talking with her partner.
- B. irritable and needs frequent repetition of directions.
- C. expelling feces and the fetal head is crowning.
- D. reading a magazine and talking on the phone.
Correct Answer: B
Rationale: The correct answer is B. In the transition stage of labor, the cervix dilates from 8 to 10 cm. This stage is characterized by intense contractions, increased irritability, and the need for frequent repetition of directions due to the intensity of labor pain. The client being irritable and needing frequent repetition of directions indicates that she is likely in the transition stage of labor.
A: Walking around and talking with her partner is more indicative of the early stage of labor.
C: Expelling feces and the fetal head crowning are more indicative of the second stage of labor.
D: Reading a magazine and talking on the phone are not typical behaviors during the transition stage of labor.
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Which site is preferred for giving an IM injection to a newborn?
- A. Ventrogluteal
- B. Vastus lateralis
- C. Rectus femoris
- D. Dorsogluteal
Correct Answer: B
Rationale: The correct answer is B: Vastus lateralis. The vastus lateralis muscle is preferred for IM injections in newborns due to its large muscle mass, minimal risk of injury to major blood vessels and nerves, and easy accessibility. It is also recommended by healthcare guidelines for infants. Ventrogluteal and dorsogluteal sites are not recommended for newborns due to the risk of damaging nerves and blood vessels. The rectus femoris muscle is not typically used for IM injections in newborns as it is less accessible and has a higher risk of injury.
If a pregnant client diagnosed with gestational diabetes cannot maintain control of her blood sugar by diet alone, which medication will she receive?
- A. Metformin (Glucophage)
- B. Glucagon
- C. Insulin
- D. Glyburide (DiaBeta)
Correct Answer: C
Rationale: The correct answer is C: Insulin. Insulin is the preferred medication for managing gestational diabetes as it is safe for the fetus and provides precise blood sugar control. Metformin (A) and Glyburide (D) are alternatives if insulin is not tolerated, but they may cross the placenta and have potential risks. Glucagon (B) is not used for diabetes management but for treating severe hypoglycemia.
A nurse is collecting data on a 3-year-old child with eczema in an outpatient center.
- A. "Cover the crib mattress with a plastic cover."'
- B. "Give the child a bubble bath for 20 min each day."'
- C. "Place a humidifier in the child's room."'
- D. "Dress the child in warm wool clothing in cold weather."'
Correct Answer: C
Rationale: The correct answer is C, "Place a humidifier in the child's room." This is because eczema can worsen with dry skin, and a humidifier can help maintain moisture in the air, preventing skin dryness. Choice A is incorrect as a plastic cover can trap heat and sweat, exacerbating eczema. Choice B is incorrect as bubble baths can irritate sensitive skin. Choice D is incorrect as wool clothing can be abrasive and trigger eczema flare-ups.
A nurse on a pediatric unit is assigned to care for a child with Reye syndrome. Which of the following is the most serious clinical manifestation for which the nurse should monitor?
- A. Anaphylaxis
- B. Cerebral edema
- C. Impaired coagulation
- D. Hypervolemia
Correct Answer: B
Rationale: The correct answer is B: Cerebral edema. In Reye syndrome, cerebral edema is the most serious manifestation due to increased intracranial pressure, potentially leading to brain damage or death. Anaphylaxis (A) is not typically associated with Reye syndrome. Impaired coagulation (C) can occur but is not as immediately life-threatening as cerebral edema. Hypervolemia (D) is a possible complication but not as critical as cerebral edema in Reye syndrome.
A nurse is caring for a 14-year-old child with appendicitis who has a pain rating of 8 on a scale of 1 to 10. The child has just returned to the unit after a computed tomography (CT) scan of the abdomen and tells the nurse the pain just stopped. Which of the following should the nurse do first?
- A. "The illness requires careful attention to fluid balance since hyperglycemia contributes to dehydration."'
- B. "Exercise requires additional insulin since glucose will be released from the cells during activity."'
- C. "Urine glucose must be monitored because there is a correlation between simultaneous glycosuria and blood glucose concentrations."'
- D. "The diet needs to include fewer complex carbohydrates because they quickly raise blood glucose."'
Correct Answer: A
Rationale: The correct answer is A because in this scenario, the child's sudden relief from pain after a CT scan could indicate a possible rupture of the appendix. This is a critical situation that requires immediate attention to prevent complications such as peritonitis. Monitoring fluid balance is crucial to prevent dehydration, especially if surgery is needed. Choices B, C, and D are incorrect and not the priority as they focus on managing diabetes, which is not the primary concern in this case. Monitoring glucose levels, adjusting insulin, or modifying the diet are not immediate actions required for a child with suspected appendicitis.