Nokea
A new mother receives instructions about care of her newborn son's circumcision. Which statement made by the mother indicates that further teaching is needed?
- A. I will call the doctor if my baby's penis starts to bleed.
- B. I should wash off any yellowish mucous on my baby's penis.
- C. I will put vaseline on his penis every time I change his diaper.
- D. I should give my baby a sponge bath for the first week.
Correct Answer: B
Rationale: The correct answer is B. Washing off yellowish mucous is not recommended as it may be a normal part of the healing process after circumcision. The yellowish mucous is likely to be a scab or healing tissue, and washing it off could interfere with the healing process or cause infection. It is essential to let it fall off naturally. Choices A, C, and D are correct because calling the doctor for bleeding, applying vaseline for protection, and giving a sponge bath for hygiene are appropriate post-circumcision care.
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A nurse in a prenatal clinic who reports that her menstrual period is 2 wks late. The client appears anxious and asks the nurse if she is pregnant. Which of the following responses should the nurse make?
- A. You can miss your period for several other reasons, describe your typical menstrual cycle.
- B. If you have been sexually active and haven't used protection, it is likely that you are pregnant.
- C. Let's check to see if you have any other signs of pregnancy, have you noticed any abdominal enlargement yet?
- D. Because you have missed your period, you should try taking a home pregnancy test before you start worrying.
Correct Answer: A
Rationale: Correct Answer: A
Rationale: Response A is the most appropriate because it addresses the client's concerns while also gathering more information. By asking the client to describe her typical menstrual cycle, the nurse can explore other potential reasons for the missed period, such as stress or hormonal imbalances. This approach shows empathy and helps the nurse to provide personalized care based on the client's individual situation.
Summary of Other Choices:
B: This response assumes pregnancy without gathering more information or considering other possibilities, potentially causing unnecessary worry or anxiety.
C: Asking about abdominal enlargement is a specific sign of pregnancy and may not be relevant at this early stage. It also does not address the client's anxiety directly.
D: While suggesting a home pregnancy test is important, it does not address the client's anxiety or gather more information about her menstrual cycle.
With routine prenatal screening, a woman in the second trimester of pregnancy is confirmed to have gestational diabetes. How may the nurse explain the role of diet and insulin in the management of blood sugar during pregnancy?
- A. You will need to take an oral hypoglycemic, which is a pill to lower your blood sugar.
- B. Insulin lowers an elevated blood sugar during pregnancy to meet the increased metabolic needs of the baby.
- C. There is a good possibility you will be taking insulin for the rest of your life.
- D. You should eat three large meals per day to maintain steady glucose load.
Correct Answer: B
Rationale: The correct answer is B: Insulin lowers an elevated blood sugar during pregnancy to meet the increased metabolic needs of the baby. During pregnancy, the placenta produces hormones that can make it difficult for insulin to work effectively, leading to gestational diabetes. Insulin helps to lower blood sugar levels in the mother, which in turn provides the necessary glucose for the developing baby's growth and development. The other choices are incorrect because: A) Oral hypoglycemics are not typically prescribed during pregnancy due to potential risks to the baby. C) Gestational diabetes usually resolves after delivery and does not require lifelong insulin use. D) Eating three large meals per day can cause blood sugar spikes and is not recommended for managing gestational diabetes.
A nurse is caring for an infant with a history of vomiting due to gastroenteritis. Which of the following nursing interventions is considered the priority?
- A. Place the infant in a side or semi-reclined position.
- B. Administer oral rehydration and electrolyte therapy.
- C. Administer antiemetic medications as prescribed.
- D. Maintain a high-carbohydrate intake to prevent ketosis.
Correct Answer: A
Rationale: Positioning the infant prevents aspiration, which is the highest priority.
Which preoperative nursing interventions should be included for a client who is scheduled to have an emergency cesarean birth?
- A. Monitor oxygen saturation and administer pain medication.
- B. Assess vital signs every 15 minutes and instruct the client about postoperative care. Alleviate anxiety and insert an indwelling catheter.
- C. Perform a sterile vaginal examination and assess breath sounds.
- D. Because this is an emergency, surgery must be performed quickly. Anxiety of the client and the family will be high. Inserting an indwelling catheter helps to keep the bladder empty and free from injury when the incision is made.
Correct Answer: B
Rationale: The correct answer is B. Assessing vital signs every 15 minutes is crucial in an emergency cesarean birth to monitor the client's condition. Instructing the client about postoperative care ensures they are well-prepared. Alleviating anxiety is important for the client's emotional well-being. Inserting an indwelling catheter is also necessary for bladder emptying to prevent injury during surgery. Choice A is incorrect because oxygen saturation monitoring is not typically a preoperative intervention for a cesarean birth, and administering pain medication may not be necessary preoperatively. Choice C is incorrect as a sterile vaginal examination is not indicated before a cesarean birth, and assessing breath sounds does not directly relate to preoperative care for this procedure. Choice D is incorrect because although anxiety management and indwelling catheter insertion are important, the rationale provided is not directly related to preoperative care for a cesarean birth.
Which procedure should be avoided for the client known to have a placenta previa?
- A. A non-stress test
- B. A urinary catheterization
- C. A sterile vaginal exam
- D. An abdominal ultrasound
Correct Answer: C
Rationale: The correct answer is C: A sterile vaginal exam. Placenta previa involves the placenta partially or fully covering the cervix, making a vaginal exam risky due to potential disruption of the placenta and causing severe bleeding. This procedure should be avoided to prevent harm to the client and the baby. A: A non-stress test, D: An abdominal ultrasound, and B: A urinary catheterization are safe procedures that do not pose a risk to the client with placenta previa.