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A neonate born at 34 weeks' gestation and weighing 6lbs, 10oz (2750g) is admitted to the nursery, The vital signs are: apical heart rate 130; respiration 58, BP- 60/20. Temp. 98 degrees F; Apgar score of 4 and 8. The nurse should designate the highest priority health outcomes to be:
- A. Oxygenation will remain adequate
- B. Body temperature will remain stable
- C. Weight will increase by 30g per day
- D. Heart rate will recover to an acceptable range
Correct Answer: A
Rationale: Oxygenation is critical for pre-term infants.
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The nurse is caring for a 14-year-old boy with a growth hormone deficiency. Which action best reflects using the nursing process to provide quality care to children and their families?
- A. Reviewing the effectiveness of interventions
- B. Questioning the facility standards for care
- C. Earning continuing education credits
- D. Ensuring reasonable costs for care provided
Correct Answer: A
Rationale: The nursing process is used to care for the child and family during health promotion, maintenance, restoration, and rehabilitation. Reviewing the effectiveness of interventions is related to outcome evaluation in the nursing process.
The nurse is assessing a postpartum client who delivered 2 hours ago. What finding requires immediate action?
- A. Fundus firm and midline.
- B. Lochia rubra with small clots.
- C. Boggy fundus above the umbilicus.
- D. Client reports perineal discomfort.
Correct Answer: C
Rationale: A boggy fundus indicates uterine atony, increasing the risk of hemorrhage.
The best indication that correct attachment to the breast has occurred is when the:
- A. Baby's tongue is securely on top of the nipple.
- B. Baby's mouth covers most of the areolar surface
- C. Baby makes frequent loud clucking sounds while nursing at each breast d, Baby sucks each breast vigorously for five minutes before falling asleep
Correct Answer: B
Rationale: The best indication that correct attachment to the breast has occurred is when the baby's mouth covers most of the areolar surface. This is important because proper latch and attachment are crucial for effective breastfeeding. When the baby's mouth covers most of the areola, it ensures that the baby is latched onto the breast properly, allowing them to feed efficiently and receive an adequate amount of milk. This also helps prevent nipple soreness and pain for the mother. Additionally, when the baby's mouth covers most of the areola, it helps ensure that the baby is positioned correctly to effectively stimulate milk production and flow.
What comment by a perimenopausal client indicates the need for further teaching?
- A. The calendar method is the most reliable method for me to use.
- B. If I use the IUD, I am at minimal risk for pelvic inflammatory disease.
- C. I should still use birth control even though I had only 2 periods last year.
- D. The contraceptive patch contains both estrogen and progesterone.
Correct Answer: A
Rationale: The calendar method is unreliable for perimenopausal women.
In teaching parents to use a bulb syringe to suction an infant, the nurse should teach them to:
- A. suction the back of the throat vigorously.
- B. always suction the nose before suctioning the mouth.
- C. use it only once a day.
- D. insert the syringe into the sides of the mouth.
Correct Answer: B
Rationale: Suctioning the nose first prevents pushing secretions further down the throat.