Nokea
A nurse is assessing a newborn who is 10 hr olWhich of the following findings should the nurse report to the provider?
- A. Axillary temperature 36.5° C (97.7° F)
- B. Nasal flaring
- C. Heart rate 158/min
- D. One void since birth
Correct Answer: B
Rationale: Nasal flaring is a sign of respiratory distress in a newborn, which may indicate underlying conditions such as transient tachypnea or respiratory infection. Prompt evaluation and intervention are necessary to ensure adequate oxygenation.
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The nurses working at a newly established birthing center have begun to compare their performance in providing maternal-newborn care against clinical standards. This comparison process is most commonly known as what?
- A. Best practices network
- B. Clinical benchmarking
- C. Outcomes-oriented practice
- D. Evidence-based practice
Correct Answer: C
Rationale: Outcomes-oriented practice measures the effectiveness of interventions and quality of care against benchmarks or standards.
What is a patient statement that indicates effective teaching after a new diagnosis of nonlactational mastitis?
- A. “I will avoid wearing a bra until I feel better.”
- B. “I should take steps to stop smoking cigarettes.”
- C. “Applying an ice pack to my breasts can help reduce pain.”
- D. “I should take the prescribed antibiotics until I feel better.”
Correct Answer: D
Rationale: The statement "I should take the prescribed antibiotics until I feel better" indicates effective teaching after a new diagnosis of nonlactational mastitis. Nonlactational mastitis is commonly treated with antibiotics to help clear up the infection. It is crucial for the patient to follow the prescribed antibiotic regimen as directed by their healthcare provider to ensure the infection is fully treated and to prevent it from worsening or recurring. Compliance with the antibiotic treatment plan is essential for successful management of nonlactational mastitis.
The nurse is providing instruction to the newly delivered client regarding postbirth uterine and vaginal discharge, called lochiWhich statement is the most appropriate?
- A. Lochia is similar to a light menstrual period for the first 6 to 12 hours.
- B. It is usually greater after cesarean births.
- C. Lochia will usually decrease with ambulation and breastfeeding.
- D. It should smell like normal menstrual flow unless an infection is present.
Correct Answer: D
Rationale: Lochia should smell like normal menstrual flow; an offensive odor usually indicates an infection.
A client is scheduled for surgery after a recent breast cancer diagnosis. The nurse is discussing the procedure with the client. To allay her fears, which explanation best describes a skin-sparing mastectomy?
- A. Removal of the breast, nipple, and areola, leaving only the skin
- B. Removal of the breast, nipple, areola, and axillary node dissection
- C. Incision on the outside of the breast, leaving the nipple intact
- D. Removal of both breasts in their entirety
Correct Answer: A
Rationale: A skin-sparing mastectomy involves removing the breast, nipple, and areola while keeping the skin intact for possible reconstruction.
The nurse is providing care to the adult female patient who presents to the emergency department with a suspected myocardial infarction (MI). Which symptom indicates a possible MI for the female patient?
- A. Chest pain that radiates to the right arm and jaw
- B. Episodic nausea/indigestion and palpitations
- C. Sudden onset of trouble walking, and loss of balance
- D. Swelling of the feet and shortness of breath
Correct Answer: B
Rationale: For female patients, the classic symptom of a myocardial infarction (MI) is often different from that in male patients. While chest pain that radiates to the right arm and jaw is a common symptom in male patients, female patients may present with more subtle symptoms. Episodic nausea/indigestion and palpitations are more commonly seen in female patients experiencing a myocardial infarction. It is important for healthcare providers to recognize and consider these atypical symptoms in female patients to ensure timely diagnosis and treatment.