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A mother brings her male preschooler to the clinic because he has had diarrhea, vomiting, and high fevers for the past three days. The child begins to cry and cling to his mother when the nurse enters the examination room. Which action should the nurse implement to get the child to cooperate?
- A. Complete the assessment while allowing the child to cry.
- B. Explain to the child the reasons an examination is needed.
- C. Talk to the mother and gradually focus on the child's toy.
- D. Request extra staff to help with the nursing assessments.
Correct Answer: C
Rationale: Engaging the mother and using the child's toy as a distraction builds trust, reducing anxiety and encouraging cooperation.
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Which is the most important assessment for the nurse to conduct following the administration of epidural anesthesia to a client who is at 40-weeks gestation?
- A. Variability of fetal heart rate.
- B. Station of presenting part.
- C. Level of pain sensation.
- D. Maternal blood pressure.
Correct Answer: D
Rationale: Monitoring maternal blood pressure detects hypotension from epidural-induced vasodilation, preventing reduced placental perfusion.
A nurse is speaking with a client who is addicted to heroin and who just learned that she is pregnant. The client states, 'I just started taking methadone. Is there anything else I can do to make sure my baby is healthy?' Which information should the nurse provide?
- A. Describe genetic testing protocols.
- B. Sign up for group therapy sessions.
- C. Start a prenatal care plan as soon as possible.
- D. Discontinue the methadone right away.
Correct Answer: C
Rationale: Early prenatal care monitors methadone effects, fetal development, and complications like neonatal abstinence syndrome, ensuring a healthy pregnancy.
Based on the assessment findings, the priority diagnosis suspected is... This diagnosis places the client at risk of...
- A. Mastitis
- B. Engorgement
- C. Blocked milk duct
- D. Inflammatory breast cancer
- E. Abscess
- F. Breastfeeding intolerance
- G. Nipple thrush
Correct Answer: A
Rationale: Mastitis, indicated by fever, localized breast symptoms, and systemic signs, is the priority diagnosis. It risks progressing to an abscess if untreated, requiring prompt intervention.
The nurse is providing preconception counseling. Which supplement should the nurse recommend to help prevent the occurrence of anencephaly?
- A. Folic acid.
- B. Iron.
- C. Vitamin D.
- D. Calcium.
Correct Answer: A
Rationale: Folic acid (400-800 mcg daily) prevents neural tube defects like anencephaly by supporting neural tube closure.
The parent of an 11-year-old client who has juvenile idiopathic arthritis tells the nurse, 'I really don't want my child to become dependent on pain medication, so I only allow taking the medication when the pain is really bad.' Which information is most important for the nurse to provide this parent?
- A. Giving pain medication around the clock helps control the pain.
- B. The use of hot baths can be used as an alternative for pain medication.
- C. The child should be encouraged to rest when experiencing pain.
- D. Encourage quiet activities such as watching television as a pain distracter.
Correct Answer: A
Rationale: Scheduled pain medication maintains consistent pain control, reduces inflammation, and prevents severe pain episodes in juvenile idiopathic arthritis, improving mobility and preventing joint damage.