Nokea
A mother infected with hepatitis B asks the nurse about the possibility of breastfeeding her neonate. Which response by the nurse would be most appropriate?
- A. Yes, breastfeeding is an acceptable option.
- B. No, you should not breastfeed your baby.
- C. Yes, breastfeeding is an acceptable option once your baby is immunized with the hepatitis B vaccine.
- D. Bottled formula is just as nutritious for your baby.
Correct Answer: C
Rationale: Breastfeeding is safe for hepatitis B-positive mothers if the neonate is vaccinated and receives immunoglobulin, reducing transmission risk.
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The nurse is assessing a client who is suspected of having a diagnosis of testicular cancer. Which data will be most helpful for determining the client's risk for this type of cancer?
- A. Race
- B. Marital status
- C. Number of children
- D. Number of sexual partners
Correct Answer: A
Rationale: Race is a key risk factor for testicular cancer, with higher incidence in White males compared to other groups. Marital status, number of children, and sexual partners are not established risk factors for this cancer.
The nurse is discussing developmental stages with the mother of a six-month-old infant. Which statement indicates an unexpected deviation from normal development?
- A. The infant is walking alone by 15 months.
- B. The infant waves good-bye by 7 months.
- C. The infant rolls from the tummy to the side at 12 months.
- D. The infant transfers a toy from one hand to the other at age 9 months.
Correct Answer: C
Rationale: Rolling tummy to side should occur by 6 months; delay to 12 months is concerning. Other milestones are age-appropriate or expected later.
The nurse has given the client with a nonplaster (fiberglass) leg cast instructions regarding cast care at home. The nurse determines that the client needs further teaching if the client makes which statement?
- A. I should avoid walking on wet, slippery floors.
- B. I'm not supposed to scratch the skin underneath the cast.
- C. It's all right to wipe dirt off of the top of the cast with a damp cloth.
- D. If the cast gets wet, I can dry it with a hair dryer turned to the hot setting.
Correct Answer: D
Rationale: Using a hair dryer on a hot setting to dry a wet fiberglass cast can cause burns or damage the cast. Avoiding slippery floors, not scratching under the cast, and wiping the cast with a damp cloth are correct care instructions.
Which problems should the nurse counsel adoptive parents about encountering? Select all that apply.
- A. Setting unrealistically high standard for themselves
- B. Lacking basic knowledge about the child's biological health history
- C. Having difficulty assimilating if the child is adopted from another country
- D. Having difficulty deciding when and how to tell the child about being adopted
- E. Feeling the need for more assistance and support in child-rearing than biological parents do
- F. Dealing with feelings of loss and grief in the child regarding family social history and traditions
Correct Answer: A,B,C,D,F
Rationale: Adoptive parents may add pressure to themselves by setting unrealistically high standards for themselves. Additional problems adoptive families may face include possible lack of knowledge about the child's biological health history, difficulty assimilating if the child is adopted from another country, difficulty deciding when and how to tell the child about being adopted, and dealing with social and traditional issues of the biological family. Otherwise, most problems faced by adoptive parents are no different from those encountered by natural parents. All parents want to be good parents. Both adoptive parents and biological parents need information, support, and guidance to prepare them to care for their child.
The nurse is preparing to assess cranial nerve VIII on a client. Which tests will the nurse perform? Select all that apply.
- A. Allen's test
- B. Phalen's test
- C. the Rinne test
- D. the Weber test
Correct Answer: C,D
Rationale: Cranial nerve VIII (vestibulocochlear) is assessed with the Rinne and Weber tests for hearing. Allen's and Phalen's tests assess circulation and carpal tunnel, respectively.