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A nurse is assessing a client who has gestational diabetes and is experiencing hyperglycemia. Which of the following findings should the nurse expect?
- A. Reports increased urinary output
- B. Diaphoresis
- C. Reports blurred vision
- D. Shallow respirations
Correct Answer: A
Rationale: The correct answer is A: Reports increased urinary output. In hyperglycemia, the body tries to eliminate excess glucose through urine, leading to increased urinary output. This is known as osmotic diuresis. Diaphoresis (B) is sweating, which is not typically associated with hyperglycemia. Blurred vision (C) is a symptom of prolonged hyperglycemia affecting the eyes but not an immediate finding. Shallow respirations (D) are not directly related to hyperglycemia.
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A client asks the nurse about the benefits of breastfeeding. Which response by the nurse provides the most accurate information?
- A. Breastfeeding helps women lose weight faster.
- B. Breast milk contains a greater amount of protein.
- C. Breast milk is easier to digest than formula.
- D. Breastfeeding is a good method of contraception.
Correct Answer: C
Rationale: The correct answer is C: Breast milk is easier to digest than formula. Breast milk contains specific enzymes and antibodies that aid in digestion and are easily absorbed by the baby's immature digestive system. This promotes better nutrient absorption and reduces the risk of digestive issues. Option A is incorrect because weight loss varies for each woman and should not be the primary reason for breastfeeding. Option B is incorrect as breast milk has a balanced composition of nutrients, not just higher protein content. Option D is incorrect as breastfeeding is not a reliable form of contraception.
The nursery nurse reviews a newborn's birth history and notes that the Apgar scores were 5 at one minute after birth, and 7 at five minutes after birth. How should the nurse interpret these scores? The infant:
- A. Needed brief oral and nasal suctioning.
- B. Required endotracheal intubation and bagging with a hand-held resuscitator.
- C. Was stillborn and required CPR.
- D. Required physical stimulation and supplemental oxygen.
Correct Answer: D
Rationale: The correct answer is D: Required physical stimulation and supplemental oxygen. The Apgar score assesses a newborn's overall condition at birth based on five criteria: heart rate, respiratory effort, muscle tone, reflex irritability, and color. A score of 5 at one minute indicates the infant needed assistance, such as stimulation to breathe and oxygen support. The score of 7 at five minutes shows improvement but still requires some intervention. Choices A, B, and C are incorrect because they suggest more aggressive interventions that are not indicated based on the Apgar scores provided, as the infant's condition was not critical enough to warrant those actions.
During the postpartum period, a hospitalized client complains of discomfort related to her episiotomy. The nurse assigns the diagnosis of 'pain related to perineal sutures.' Which nursing intervention is most appropriate during the first 24 hours following an episiotomy?
- A. Instruct the client to use petroleum jelly on the episiotomy after voiding.
- B. Encourage the client to practice Kegel exercises.
- C. Advise the client to take a warm sitz bath every four hours.
- D. Apply ice packs to the perineum.
Correct Answer: D
Rationale: The correct answer is D: Apply ice packs to the perineum. Ice packs help reduce swelling and provide numbing relief, which can help alleviate pain in the immediate postpartum period. Applying ice packs during the first 24 hours can also promote vasoconstriction, reducing the risk of bleeding and infection.
Incorrect options:
A: Using petroleum jelly can increase the risk of infection and hinder wound healing.
B: Kegel exercises are beneficial for pelvic floor strengthening but are not the most appropriate intervention for immediate pain relief.
C: While sitz baths can be soothing, they may not be suitable within the first 24 hours post-episiotomy as they can increase blood flow and potentially worsen swelling.
Overall, ice packs are the most effective and appropriate intervention for pain management in the immediate postpartum period.
A nurse is reinforcing teaching about accidental poisoning to a parent during a routine well-child visit.
- A. "I will give my child a dose of ipecac."'
- B. "I will place my child on her back."'
- C. "I will call the Poison Control Center."'
- D. "I will get my child to drink a full glass of water."'
Correct Answer: C
Rationale: The correct answer is C: "I will call the Poison Control Center." This is the best course of action in case of accidental poisoning as they provide expert advice on managing poison exposure. Calling them ensures prompt and accurate guidance to prevent further harm. Option A (ipecac) is not recommended anymore as it can cause more harm. Option B (placing the child on her back) is irrelevant to poisoning treatment. Option D (full glass of water) is not recommended as it can dilute the poison and may worsen the situation.
An 8-year-old child is admitted to a pediatric unit with a fractured femur and is placed in skeletal traction. Which of the following nursing interventions is the most appropriate?
- A. Position the weights securely against the foot of the bed.
- B. Provide small frequent high-fat meals to the child.
- C. Compare pulses on affected site to contralateral side.
- D. Provide diversional activities to minimize the child's movement.
Correct Answer: C
Rationale: The correct answer is C: Compare pulses on affected site to contralateral side. This is the most appropriate nursing intervention because it assesses for any circulatory compromise due to the skeletal traction. Checking pulses helps monitor perfusion distal to the fracture site and ensures early detection of any complications like compartment syndrome. Positioning the weights against the foot of the bed (A) is incorrect as it can cause uneven traction. Providing high-fat meals (B) and diversional activities (D) are irrelevant to the immediate care of the child's fracture.