Nokea
A multiparous client delivers dizygotic twins at 37 weeks' gestation. The twin neonates require additional hospitalization after the client is discharged. In planning the family's care, an appropriate goal for the nurse to formulate is that, while the twins are hospitalized, the parents will do which of the following?
- A. Discuss how they will cope with twin infants at home.
- B. Participate in care of the twins as much as possible.
- C. Take turns providing 24-hour observation of the twins.
- D. Identify complications that may occur as the twins develop.
Correct Answer: B
Rationale: Parental participation in twin care during hospitalization promotes bonding, confidence, and skill development. Discussing coping, 24-hour observation, or identifying complications are less immediate or unrealistic.
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Which of the following statements by the mother of a neonate diagnosed with bronchopulmonary dysplasia (BPD) indicates effective teaching?
- A. BPD is an acute disease that can be treated with antibiotics.'
- B. My baby may require permanent assisted ventilation.'
- C. Bronchodilators can cure my baby's condition.'
- D. My baby may have seizures later on in life because of this condition.'
Correct Answer: B
Rationale: BPD is a chronic lung condition that may require long-term respiratory support, including permanent assisted ventilation.
A primigravid client at 38 weeks' gestation is admitted to the labor suite in active labor. The client's physical assessment reveals a chlamydial infection. The nurse explains that if the infection is left untreated, the neonate may develop which of the following?
- A. Conjunctivitis.
- B. Heart disease.
- C. Skin lesions.
- D. Hepatitis.
Correct Answer: A
Rationale: Untreated chlamydia during delivery can cause neonatal conjunctivitis (ophthalmia neonatorum) via transmission through the birth canal. Heart disease, skin lesions, and hepatitis are not associated with chlamydia.
Fifteen minutes after a client experiences an eclamptic seizure, the nurse should assess the client for which of the following?
- A. Polyuria.
- B. Facial flushing.
- C. Hypotension.
- D. Uterine contractions.
Correct Answer: D
Rationale: Uterine contractions should be assessed post-seizure to evaluate labor status.
The nurse managing the admission nursery is beginning the shift. There are 2 infants under the care of a primary staff nurse and are remaining in the nursery while their mothers sleep. One newborn is waiting to be transferred to the special care nursery (SCN) with a diagnosis of possible sepsis. The SCN cannot accept a transfer for 30 minutes. The nurse has been notified that another infant has been born and is breathing at a rate of 80 bpm and needs to be admitted to the nursery. There are also two infants who are waiting for social services to determine discharge plans. There can be no other additions to the nursery until at least one newborn leaves the area. How should the nurse manage this situation?
- A. Ask the nurses in SCN if they can take the newborn with possible sepsis now.
- B. Ask the primary staff nurses to take their babies back to the sleeping mothers' rooms.
- C. Call social services to determine if either of the babies who are waiting to be discharged are ready to leave.
- D. Ask the nurse with the infant who is breathing at 80 bpm to wait ½ hour.
Correct Answer: C
Rationale: Calling social services to expedite discharge of one of the waiting infants allows space for the new admission with a high respiratory rate, which requires urgent assessment.
A nurse is discussing sterilization with a male client. Which of the following statements by the nurse is accurate?
- A. A vasectomy is effective immediately.
- B. A vasectomy requires a follow-up sperm count to confirm sterility.
- C. A vasectomy prevents testosterone production.
- D. A vasectomy is reversible in all cases.
Correct Answer: B
Rationale: A vasectomy requires a follow-up sperm count to confirm sterility, as sperm may remain in the vas deferens initially. It is not effective immediately, does not affect testosterone production, and reversal is not always successful.