Nokea
A nurse is caring for a 4-year-old child who is prescribed an intravenous medication preoperatively. Which of the following therapeutic play techniques is most appropriate when reinforcing the teaching for this procedure?
- A. Role play with another nurse the technique of IV placement and how the medication is infused.
- B. Read a story that explains the basics of how IVs are placed.
- C. Watch a movie narrated by nurses and children about IV placement.
- D. Explain the basic procedure and give the child IV supplies to play with minus the needle.
Correct Answer: D
Rationale: The correct answer is D because explaining the basic procedure and providing the child with IV supplies to play with (minus the needle) allows the child to familiarize themselves with the equipment in a non-threatening manner. This technique helps reduce anxiety and fear associated with the procedure. Role-playing may not be suitable for all children as it can be too abstract for a 4-year-old. Reading a story may not provide the hands-on experience needed to understand the procedure. Watching a movie may not be interactive enough for the child to actively engage in the learning process. Providing IV supplies for play is the most appropriate therapeutic play technique for a 4-year-old to prepare them for the IV placement procedure.
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Immediately after birth, the nurse places the newborn under a radiant warmer. Which is the primary rationale for the nurse's action?
- A. To facilitate an efficient means of thermoregulation
- B. To facilitate initial assessment by the nurse
- C. To permit the use of the cardiac monitor
- D. To permit close observation by the family members
Correct Answer: A
Rationale: The correct answer is A: To facilitate an efficient means of thermoregulation. Placing the newborn under a radiant warmer helps prevent hypothermia by maintaining the baby's body temperature. Newborns have difficulty regulating their own body temperature initially, so the radiant warmer provides a controlled environment to keep them warm. Choice B is incorrect because the primary reason is not for assessment but for thermoregulation. Choice C is incorrect as a cardiac monitor is not typically needed immediately after birth. Choice D is incorrect as the primary focus is on the newborn's well-being, not family observation.
A woman enters the birthing center in active labor. She tells the nurse that her membranes ruptured 26 hours ago. The nurse immediately takes the client's vital signs. Which is the rationale for the nurse's actions?
- A. Pulse rates rise the longer the membranes are ruptured
- B. Respiratory rates decrease due to lack of fluid in the uterus
- C. Prolonged rupture of membranes can lead to transient hypertension
- D. Infection is a complication of prolonged rupture of membranes
Correct Answer: D
Rationale: The correct answer is D. When the membranes rupture, it increases the risk of infection as it provides a direct pathway for bacteria to enter the uterus. Taking vital signs is crucial to monitor for signs of infection such as fever, tachycardia, and hypotension. Elevated temperature and increased heart rate can indicate an infection. Choice A is incorrect because pulse rate may not necessarily rise with prolonged rupture of membranes. Choice B is also incorrect as respiratory rates are not directly affected by ruptured membranes. Choice C is incorrect as prolonged rupture can lead to infection rather than transient hypertension.
A nurse is preparing to administer an intramuscular (IM) injection to a 2-month-old infant. Which of the following is the preferred injection site?
- A. "Vastus lateralis"'
- B. "Deltoid muscle"'
- C. "Ventrogluteal site"'
- D. NA
Correct Answer: A
Rationale: The correct answer is A: "Vastus lateralis." For infants, the vastus lateralis muscle in the thigh is the preferred site for IM injections due to its large size, well-developed muscle mass, and minimal major blood vessels and nerves. This reduces the risk of injury and ensures proper medication absorption. The deltoid muscle (choice B) is typically used for older children and adults, not infants. The ventrogluteal site (choice C) is more commonly used for adults and older children as well. Not Applicable (choice D) does not provide any relevant information.
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.
A client is admitted to the hospital for induction of labor. Which are the main indications for labor induction?
- A. Placenta previa and twins
- B. Pregnancy-induced hypertension and postterm fetus
- C. Breech position and prematurity
- D. Cephalopelvic disproportion and fetal distress
Correct Answer: B
Rationale: The correct answer is B: Pregnancy-induced hypertension and postterm fetus. Labor induction is commonly indicated in cases of pregnancy-induced hypertension to prevent complications such as preeclampsia. Postterm fetus is another common indication to prevent risks associated with a prolonged pregnancy, such as stillbirth. Placenta previa, twins, breech position, prematurity, cephalopelvic disproportion, and fetal distress are not typically primary indications for labor induction. Placenta previa may require a cesarean section, twins may be delivered vaginally or by C-section, breech position may require external cephalic version or C-section, prematurity may necessitate medical management, cephalopelvic disproportion may require a C-section, and fetal distress may necessitate immediate delivery but not necessarily labor induction.