Nokea
A maternal-newborn nurse is caring for a mother who just delivered a baby born with Down syndrome. Which nursing diagnosis would be the most essential in caring for the mother of this infant?
- A. Disturbed body image
- B. Interrupted family processes
- C. Anxiety
- D. Risk for injury
Correct Answer: B
Rationale: This mother will likely experience a disruption in the family process related to the birth of a baby with an inherited disorder. Therefore, the probable nursing diagnosis for this family is 'Interrupted family processes.' Women commonly experience 'body image disturbances in the postpartum period'; however, this nursing diagnosis is unrelated to giving birth to a child with Down syndrome. The mother will likely have a mix of emotions that may include anxiety, guilt, and denial, but this nursing diagnosis is not the most essential for this family. 'Risk for injury' is not an applicable nursing diagnosis.
You may also like to solve these questions
A nurse is caring for a client who is experiencing preterm labor and has a new prescription for terbutaline. Which of the following findings is a contraindication for the administration of this medication?
- A. Heart disease
- B. Cervical dilation of 2 cm
- C. Gestational age of 34 weeks
- D. Allergy to penicillin
Correct Answer: A
Rationale: Terbutaline is a tocolytic that can cause cardiovascular side effects and is contraindicated in clients with heart disease.
The human papillomavirus (HPV), also known as genital warts, affects 79 million Americans, with an estimated number of 14 million new infections each year. The highest rate of infection occurs in young women, ages 20 to 24 years. Prophylactic vaccination to prevent HPV is now available. Which statement regarding this vaccine is inaccurate?
- A. Only one vaccine for the HPV is available.
- B. The vaccine is given in three doses over a 6-month period.
- C. The vaccine is recommended for both boys and girls.
- D. Ideally, the vaccine is administered before the first sexual contact.
Correct Answer: A
Rationale: Two vaccines for HPV are available Cervarix and Gardasil.
The nurse is providing care to a 46-year-old female patient. The patient appears hesitant when asked of her sexual history, and the nurse discovers that the patient is a lesbian. What education should the nurse provide to this patient pertaining to her health?
- A. Lesbians often are at higher risk for menstrual disorders, abnormal insulin production, and infertility.
- B. Lesbians often are at higher risk due to lower socioeconomic disparities than their heterosexual counterparts.
- C. Lesbians often refuse choices in health care such as the HPV vaccine as many feel they are not at risk.
- D. Lesbians often have fewer health issues than their heterosexual counterparts due to their strong support systems.
Correct Answer: A
Rationale: The education that the nurse should provide to the lesbian patient pertains to her health includes the fact that lesbians often are at higher risk for menstrual disorders, abnormal insulin production, and infertility. It is important for the nurse to be aware of potential health risks that may affect lesbians specifically, as this knowledge can help in providing appropriate care and interventions. By addressing these specific health concerns, the nurse can promote the patient's overall well-being and empower her to take proactive steps to maintain her health.
The patient makes the statement: “I’m afraid to take the baby home tomorrow.” Which response by the nurse would be the most therapeutic?
- A. “You’re afraid to take the baby home?”
- B. “Don’t you have a mother who can come and help?”
- C. “You should read the literature I gave you before you leave.”
- D. “I was scared when I took my first baby home, but everything worked out.”
Correct Answer: D
Rationale: The best response by the nurse in this situation would be D. By sharing a personal experience of feeling scared when taking their first baby home, the nurse is empathizing with the patient and offering reassurance that everything worked out in the end. This can help the patient feel understood and less alone in their fear, while also providing hope that things will be okay. It validates the patient's feelings and offers a positive perspective, which can be therapeutic in this situation.
Which statement regarding chromosomal abnormalities is most accurate?
- A. Chromosomal abnormalities occur in approximately 10% of newborns.
- B. Abnormalities of number are the leading cause of pregnancy loss.
- C. Down syndrome is a result of an abnormal chromosomal structure.
- D. Unbalanced translocation results in a mild abnormality that the child will outgrow.
Correct Answer: B
Rationale: Aneuploidy is an abnormality of number that is also the leading genetic cause of mental retardation. Chromosomal abnormalities occur in fewer than 1% of newborns. Down syndrome is the most common form of a trisomal abnormality, an abnormality of chromosome number (47 chromosomes). Unbalanced translocation is an abnormality of chromosomal structure that often has serious clinical effects.