Nokea
A nurse is assessing a newborn who was born vaginally with vacuum extractor assistance. The nurse notes swelling over the newborn's head that crosses the suture line. The nurse should identify the swelling as which of the following findings?
- A. Nevus ammeus
- B. Caput succedaneum
- C. Cephalohematoma
- D. Erythema toxicum
Correct Answer: B
Rationale: Caput succedaneum is a swelling that crosses suture lines due to pressure during delivery.
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While working in the prenatal clinic, nurses care for a very diverse group of clients. Which cultural factor related to health is most likely to drive acceptance of planned interventions?
- A. Educational achievement
- B. Income level
- C. Subcultural group
- D. Individual beliefs
Correct Answer: D
Rationale: Individual beliefs are the most significant factor in driving the acceptance of health care interventions, as personal values often outweigh other influences such as education or income.
A nurse is entering information on the patient’s electronic health record (EHR) and is called to assist in an emergency situation with regard to another patient in the labor and birth suite. The nurse rushes to the scene to assist; however, she leaves the chart open on the computer screen. The emergent patient situation is resolved satisfactorily, and the nurse comes back to the computer entry screen to complete charting. At the end of the shift, the nurse manager asks to speak with the nurse and tells her that she is concerned with what happened today on the unit because there was a breach in confidentiality. Which response by the nurse indicates that she understands the nurse manager’s concerns?
- A. The nurse acknowledges that she should have made sure that her patient was safe before assisting with the emergency.
- B. The nurse states that she should have logged out of the EHR prior to attending to the emergency.
- C. The nurse indicates that the unit was understaffed.
- D. The nurse indicates that the she changed her password following the clinical emergency to maintain confidentiality.
Correct Answer: B
Rationale: Step-by-step rationale:
1. The correct answer is B because logging out of the EHR prior to attending to the emergency is crucial to maintain patient confidentiality.
2. By leaving the EHR open, the nurse exposed sensitive patient information to potential unauthorized access.
3. This action violates patient privacy rights and is a breach of confidentiality.
4. Choice A is incorrect as it does not address the specific issue of breaching patient confidentiality by leaving the EHR open.
5. Choice C is irrelevant as understaffing does not excuse the breach of patient confidentiality.
6. Choice D is incorrect as changing the password after the breach does not rectify the initial mistake of leaving the EHR open.
Summary: Choice B is the correct response as it directly addresses the breach of confidentiality by acknowledging the importance of logging out of the EHR to protect patient information. Choices A, C, and D are incorrect as they do not effectively address the issue of breaching patient confidentiality.
A nurse is caring for a patient who has just been diagnosed with chlamydia and wants to know when she can have sex with her boyfriend again. What is the best response from the nurse?
- A. “You should not have sex until 7 days after you complete treatment and your partner gets treatment.”
- B. “You can have sex as soon as you finish the medicine.”
- C. “You can have sex once your partner takes the medicine.”
- D. “There is no need to wait.”
Correct Answer: A
Rationale: The correct answer is A because chlamydia is a sexually transmitted infection that requires treatment for both the infected person and their partner to prevent reinfection. The recommended practice is to abstain from sex until 7 days after completing treatment to ensure the infection is fully cleared from both individuals. This approach helps to prevent the spread of the infection and reduces the risk of complications.
Choice B is incorrect because simply finishing the medicine without waiting for the partner's treatment can lead to reinfection. Choice C is incorrect as it solely focuses on the partner's treatment without considering the completion of the patient's own treatment. Choice D is incorrect as it disregards the importance of completing treatment and waiting for the specified period before resuming sexual activity.
The health history and physical examination cannot reliably identify all persons infected with HIV or other blood-borne pathogens. Which infection control practice should the nurse use when providing eye prophylaxis to a term newborn?
- A. Wear gloves.
- B. Wear mouth, nose, and eye protection.
- C. Wear a mask.
- D. Wash the hands after medication administration.
Correct Answer: A
Rationale: Standard precautions require the use of gloves when providing eye prophylaxis to a newborn.
What condition is associated with advanced paternal age?
- A. Autosomal dominant disorder
- B. Schizophrenia
- C. Autism spectrum disorder
- D. Down syndrome
Correct Answer: D
Rationale: Advanced paternal age increases the risk of autosomal dominant disorders, schizophrenia, and autism spectrum disorder, but not Down syndrome, which is linked to maternal age.