Nokea
A new mother asks the nurse why newborns receive an injection of vit. K after delivery. What will be the best response from the nurse?
- A. Newborns are given vit K to help with the digestion to help them absorb fat soluble vitamins
- B. Newborns are given vit K and erythromycin ointment to help prevent ophthalmia neonatorum
- C. Newborns lack the intestinal flora needed to produce vit K, so it is given to prevent bleeding episodes
- D. This vitamin substitutes for vitamin C and newborns will strengthen their immune system
Correct Answer: C
Rationale: The correct answer is C. Newborns lack the intestinal flora needed to produce vitamin K, so it is given to prevent bleeding episodes. Vitamin K is essential for blood clotting, and newborns have lower levels at birth. Without enough vitamin K, newborns are at risk of bleeding issues. Giving them a vitamin K injection helps prevent potential bleeding disorders.
Choice A is incorrect because vitamin K is not given for digestion or fat absorption. Choice B is incorrect as erythromycin ointment is used for preventing eye infections, not related to vitamin K injections. Choice D is incorrect as vitamin K does not substitute for vitamin C, and it is not primarily for strengthening the immune system.
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A client at 35 weeks' gestation reports sharp abdominal pain and vaginal bleeding. What condition should the nurse suspect?
- A. Placenta previa.
- B. Abruptio placentae.
- C. Preterm labor.
- D. Chorioamnionitis.
Correct Answer: B
Rationale: The correct answer is B: Abruptio placentae. This condition presents with sharp abdominal pain and vaginal bleeding, typically occurring in the third trimester. It is caused by the premature separation of the placenta from the uterine wall. The pain is often severe due to the bleeding and can lead to fetal distress. Placenta previa (A) presents with painless vaginal bleeding, preterm labor (C) typically involves regular contractions and cervical changes, and chorioamnionitis (D) is characterized by fever and uterine tenderness.
Developing a plan to achieve patient outcomes is included in which step of the CJMM?
- A. prioritizing hypotheses
- B. generating solutions
- C. taking action
- D. evaluating outcomes
Correct Answer: B
Rationale: The correct answer is B: generating solutions. In the CJMM (Clinical Judgment Model in Nursing), developing a plan to achieve patient outcomes falls under the step of generating solutions. This step involves identifying and implementing interventions to address the patient's needs and achieve the desired outcomes. Prioritizing hypotheses (A) is about identifying potential issues, not developing a plan. Taking action (C) is about implementing the plan, not developing it. Evaluating outcomes (D) is the final step where the effectiveness of the plan is assessed, not where the plan is developed. Therefore, B is the correct choice as it specifically focuses on the process of creating a plan to achieve patient outcomes within the CJMM.
A nurse is reviewing the laboratory results for a client who is at 29 weeks.... the provider?
- A. WBC count
- B. 11,000/mm³ Hgb
- C. 11,2 g/Dl
- D. Hct 34% Platelets 140,000/mm³
Correct Answer: B
Rationale: The correct answer is B: 11,000/mm³ Hgb. At 29 weeks of gestation, hemoglobin (Hgb) levels are crucial to monitor for anemia in pregnant women. A Hgb level of 11,000/mm³ is within the normal range for a pregnant woman. Anemia during pregnancy can lead to adverse outcomes for both the mother and the baby, such as preterm birth and low birth weight.
Rationale for other choices:
A: WBC count - While monitoring white blood cell (WBC) counts is important for detecting infections, it is not the most relevant parameter to review in this scenario.
C: 11,2 g/Dl - This choice is incomplete and doesn't provide a specific parameter or context for interpretation.
D: Hct 34% Platelets 140,000/mm³ - Hematocrit (Hct) and platelet levels are important, but in this case, the Hgb level is more pertinent
As the infant nursery nurse, you are assisting with a
- A. Assess the fetal station delivery. After the initial assessment of the baby,
- B. Assess for rupture of the fetal membranes what is the next best action?
- C. Determine dilation of the cervix
- D. Give the infant a bath
Correct Answer: C
Rationale: Rationale for Correct Answer (C - Determine dilation of the cervix):
1. It is crucial to monitor the progress of labor by assessing cervical dilation.
2. Cervical dilation indicates the stage of labor and helps determine when the mother is ready to push.
3. This information guides the healthcare team in providing appropriate care and support during delivery.
4. Assessing fetal station or rupture of membranes is important but determining cervical dilation is the priority.
Summary:
- Option A is incorrect because assessing fetal station is not the immediate next step.
- Option B is incorrect as assessing for rupture of membranes is important but not the next immediate action.
- Option D is incorrect as giving the infant a bath is not a priority in the labor and delivery process.
What are signs of neonatal sepsis that a nurse should monitor for?
- A. Tachypnea, poor feeding, and temperature instability
- B. Increased alertness, reduced crying, and stable vitals
- C. Lethargy, poor perfusion, and apnea
- D. Hyperthermia, bradycardia, and cyanosis
Correct Answer: C
Rationale: The correct answer is C because lethargy, poor perfusion, and apnea are classic signs of neonatal sepsis. Lethargy indicates decreased activity and responsiveness, poor perfusion suggests inadequate blood circulation, and apnea is a serious respiratory issue. These signs indicate a systemic infection affecting multiple organs. Choices A, B, and D do not align with typical symptoms of neonatal sepsis. Tachypnea, poor feeding, and temperature instability (Choice A) are more general and can be seen in various conditions. Increased alertness, reduced crying, and stable vitals (Choice B) are not indicative of sepsis, as sepsis typically causes the opposite. Hyperthermia, bradycardia, and cyanosis (Choice D) can be present in sepsis, but they are not as specific or as common as the signs in Choice C.