Nokea
A nurse is caring for a 23-month-old child with iron-deficiency anemia.
- A. "Give the oral iron supplementation with a glass of cow's milk to prevent stomach problems."'
- B. "Provide diet instructions including limiting citrus fruits in favor of more vegetables."'
- C. "Provide information about complications of iron including gastrointestinal bleeding and ulcers."'
- D. "Give liquid iron through a straw placed in the back of the mouth."'
Correct Answer: D
Rationale: Correct Answer: D
Rationale:
1. Iron supplements can stain teeth, so giving liquid iron through a straw placed in the back of the mouth minimizes contact with teeth.
2. This method also helps reduce the risk of tooth decay and enamel erosion.
3. Providing iron through a straw allows for better absorption through the bloodstream.
4. It is important to maximize iron absorption in children with iron-deficiency anemia.
Summary of other choices:
A. Giving iron supplementation with cow's milk can reduce iron absorption due to calcium interference.
B. Diet instructions should focus on iron-rich foods, not just limiting citrus fruits.
C. While complications of iron deficiency should be discussed, this choice does not address treatment.
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A client at 33 weeks gestation is admitted for suspected abruptio placenta. Which factor in the client's history supports this diagnosis? The client states that she:
- A. drinks two glasses of wine before dinner every night.
- B. has intermittent contractions that are relieved by walking.
- C. had intercourse with her partner last night.
- D. used crack an hour before the symptoms began.
Correct Answer: D
Rationale: The correct answer is D: used crack an hour before the symptoms began. Abruptio placenta is a condition where the placenta prematurely separates from the uterine wall. Substance abuse, such as crack cocaine, can lead to vasoconstriction and increased risk of abruptio placenta due to compromised blood flow to the placenta. This can result in fetal distress and maternal bleeding. The other choices (A, B, C) do not directly correlate with abruptio placenta. Intermittent contractions relieved by walking are more suggestive of Braxton Hicks contractions, intercourse is not a known risk factor for abruptio placenta, and drinking wine does not typically cause this condition.
In which position should the nurse place the laboring client in order to increase the intensity of the contractions and improve oxygenation to the fetus?
- A. Supine with legs elevated
- B. Squatting
- C. Left side-lying
- D. High Fowler's
Correct Answer: C
Rationale: The correct answer is C, left side-lying position. This position promotes optimal blood flow to the placenta, enhancing oxygenation to the fetus. It also helps prevent compression of the vena cava, ensuring adequate circulation to the mother. Supine position with legs elevated (A) can compress the vena cava, reducing blood flow to the fetus. Squatting (B) may not improve oxygenation to the fetus and can be tiring for the laboring client. High Fowler's position (D) can impede blood flow to the placenta due to compression of abdominal vessels.
The client who is scheduled for a nonstress test (NST) asks the nurse to explain the purpose of the test. Which of the following is the correct response?
- A. The purpose of the NST is to assess the fetal CNS.
- B. The purpose of the NST helps to determine gestational age.
- C. The purpose of the NST is to determine fetal lie.
- D. The purpose of the NST is to determine fetal breathing.
Correct Answer: A
Rationale: The correct answer is A: The purpose of the NST is to assess the fetal CNS. The nonstress test (NST) evaluates the fetal CNS by measuring the fetal heart rate in response to fetal movement. This test assesses the overall well-being of the fetus by monitoring for accelerations in the heart rate, indicating a healthy CNS. Choices B, C, and D are incorrect because the NST is not used to determine gestational age, fetal lie, or fetal breathing. The primary focus of the NST is to evaluate the fetal CNS function through monitoring the fetal heart rate patterns.
A nurse is caring for a client who is at 22 weeks of gestation and is HIV positive. Which of the following actions should the nurse take?
- A. Administer penicillin G 2.4 million units IM to the client
- B. Instruct the client to schedule an annual pelvic examination
- C. Tell the client she will start medication for HIV immediately after delivery
- D. Report the client’s condition to the local health department
Correct Answer: D
Rationale: Rationale: Reporting the client's HIV positive status to the local health department is crucial for monitoring and preventing the spread of the infection. This action ensures proper follow-up care, contact tracing, and support services for the client and at-risk individuals. Administering penicillin G (choice A) is not indicated for HIV positive status. Instructing the client to schedule a pelvic examination (choice B) is unrelated to the client's HIV status. Delaying HIV medication until after delivery (choice C) can pose risks to both the mother and the baby.
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.