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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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Which aspect of client wellness has not been a focus of health during the 21st century ?
- A. Disease prevention
- B. Health promotion
- C. Wellness
- D. Analysis of morbidity and mortality
Correct Answer: D
Rationale: The focus on health has shifted to disease prevention, health promotion, and wellness. In the last century, much of the focus was on analyzing morbidity and mortality rates.
The nurse is providing discharge teaching to a 20-year-old mother who has had her first male child. Which statement by the mother demonstrates that she understands the discharge teaching regarding his circumcision?
- A. I will observe the whitish-yellow drainage on his penis, but I will not remove it.
- B. I will bring him back to the clinic in 3 days to have the drainage removed.
- C. I will use antibiotic ointment on his penis with every diaper change.
- D. I will rub the area briskly with a washcloth to remove the drainage.
Correct Answer: A
Rationale: Whitish-yellow drainage is normal and should not be removed.
A nurse is assessing a client who is 8 hr postpartum and multiparous. Which of the following findings should alert the nurse to the client's need to urinate?
- A. Moderate lochia rubra
- B. Fundus three fingerbreadths above the umbilicus
- C. Moderate swelling of the labia
- D. Blood pressure 130/84 mm Hg
Correct Answer: B
Rationale: A fundus three fingerbreadths above the umbilicus indicates that the uterus is not adequately contracting, which can obstruct the flow of urine from the bladder. Postpartum clients often experience urinary retention due to decreased sensation in the bladder, trauma from delivery, and decreased bladder tone. Failure to empty the bladder promptly can lead to urinary retention and potential complications such as urinary tract infections or bladder distention. Therefore, the nurse should be alert to the client's need to urinate when assessing the fundal height.
During the assessment of a newborn, it is most important for the nurse to report a:
- A. Temperature of 97.7 degrees Fahrenheit
- B. Pale pink, rust-colored stain in the diaper
- C. Heart rate that drops to 120 beats/min
- D. Breathing pattern that is diaphragmatic with sternal retractions
Correct Answer: D
Rationale: Sternal retractions indicate respiratory difficulty.
What is the LNG-IUC mechanism of action?
- A. disruption of fertilization of the egg and sperm
- B. termination of a pregnancy
- C. creation of a hostile uterine environment
- D. thickening cervical mucus, atrophic endometrium
Correct Answer: D
Rationale: The LNG-IUC, or levonorgestrel-releasing intrauterine system, works primarily by thickening the cervical mucus, which inhibits the passage of sperm through the cervix. This mechanism reduces the likelihood of fertilization occurring. Additionally, LNG-IUC also causes atrophic changes in the endometrium, which makes it less conducive for implantation of a fertilized egg, further decreasing the chance of pregnancy.