Nokea
A nurse in the antepartum clinic is assessing a client's adaptation to pregnancy. The client states that she is, ''happy one min and crying the next.'' The nurse should interpret the client's statement as an indication of which of the following?
- A. Emotional lability
- B. Focusing phase
- C. Cognitive restructuring
- D. Couvade syndrome
Correct Answer: A
Rationale: The correct answer is A: Emotional lability. Emotional lability refers to rapid, unpredictable changes in emotions. During pregnancy, hormonal fluctuations can lead to mood swings, causing the client to feel happy one minute and crying the next. Focusing phase (B) is not relevant to the client's emotional state. Cognitive restructuring (C) involves changing negative thought patterns, which is not mentioned in the scenario. Couvade syndrome (D) is a condition where male partners experience pregnancy-like symptoms, which is not applicable here.
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A nurse is reviewing discharge instructions with the parent of an infant who has acute laryngotracheobronchitis (croup).
- A. "I will give my child the corticosteroids prescribed by the doctor."'
- B. "I will clear the child's nasal passages with a bulb syringe to aid in breathing."'
- C. "I will place a dehumidifier in my child's room."'
- D. "I will encourage my child to take plenty of fluids over the next several days."'
Correct Answer: C
Rationale: The correct answer is C: "I will place a dehumidifier in my child's room."
Rationale:
1. Acute laryngotracheobronchitis (croup) is a condition that causes swelling in the upper airway, leading to breathing difficulties.
2. Placing a dehumidifier in the child's room can help maintain optimal humidity levels, which can soothe the inflamed airways and ease breathing.
3. Moist air from the dehumidifier can help reduce coughing and throat irritation, providing comfort to the child.
4. This intervention is specific to managing the symptoms of croup and can support the child's recovery.
Summary:
- Choice A: Corticosteroids are prescribed by the doctor for croup, but it is not the parent's responsibility to administer them.
- Choice B: Clearing nasal passages with a bulb syringe is not directly related to managing croup symptoms.
- Choice D: Encouraging fluids
A nurse is preparing to collect a blood specimen from a newborn via a heel stick. Which of the following techniques should the nurse use to help minimize the pain of the procedure for the newborn?
- A. Apply a cool pack for 10 minutes to the heel prior to the puncture
- B. Request a prescription for IM analgesic
- C. Use a manual lancet blade to pierce the skin
- D. Place the newborn skin to skin on the mother’s chest
Correct Answer: D
Rationale: The correct answer is D: Place the newborn skin to skin on the mother's chest. This technique, known as kangaroo care, helps minimize pain during procedures by providing comfort, warmth, and security to the newborn. The close physical contact with the mother can reduce stress and promote relaxation, leading to decreased perception of pain. Additionally, the release of oxytocin during skin-to-skin contact can further alleviate discomfort for the newborn.
Applying a cool pack (choice A) may actually increase pain and vasoconstriction, making the heel stick more uncomfortable. Requesting an IM analgesic (choice B) is unnecessary and may expose the newborn to unnecessary medications. Using a manual lancet blade (choice C) can be painful and may not provide the same comfort and pain relief as skin-to-skin contact.
A nurse is planning discharge for a client who is 3 days postpartum. Which of the following non pharmacological interventions should the nurse include in the plan of care for lactation suppression?
- A. Place warm, moist packs on the breast.
- B. Apply cabbage leaves to the breast.
- C. Wear a loose-fitting bra.
- D. Put green tea bags on the breasts.
Correct Answer: B
Rationale: The correct answer is B: Apply cabbage leaves to the breast. Cabbage leaves have been shown to help with lactation suppression due to their anti-inflammatory properties. Placing cabbage leaves on the breasts can help reduce milk supply by decreasing blood flow to the area. This method is safe, inexpensive, and easily accessible.
Choice A (Place warm, moist packs on the breast) is incorrect as warmth can actually stimulate milk production. Choice C (Wear a loose-fitting bra) is also incorrect as it does not directly address lactation suppression. Choice D (Put green tea bags on the breasts) is not effective for lactation suppression and may not be safe for the newborn if ingested.
A 17-year-old client delivered her first baby 8 hours ago. Which of the following is an indication that appropriate bonding is occurring? The client:
- A. makes eye contact with the baby.
- B. wonders why the baby cries so much.
- C. asks the nurse to help change the baby's diaper.
- D. asks the nurse if the baby is cute.
Correct Answer: A
Rationale: The correct answer is A: makes eye contact with the baby. This indicates appropriate bonding as eye contact fosters emotional connection and attachment between mother and baby. It shows the mother is engaging with her child, seeking to establish a bond. Choice B suggests lack of understanding of infant communication, choice C indicates practical caregiving rather than emotional bonding, and choice D focuses on the baby's appearance rather than emotional connection.
Which site is preferred for giving an IM injection to a newborn?
- A. Ventrogluteal
- B. Vastus lateralis
- C. Rectus femoris
- D. Dorsogluteal
Correct Answer: B
Rationale: The correct answer is B: Vastus lateralis. The vastus lateralis muscle is preferred for IM injections in newborns due to its large muscle mass, minimal risk of injury to major blood vessels and nerves, and easy accessibility. It is also recommended by healthcare guidelines for infants. Ventrogluteal and dorsogluteal sites are not recommended for newborns due to the risk of damaging nerves and blood vessels. The rectus femoris muscle is not typically used for IM injections in newborns as it is less accessible and has a higher risk of injury.