Nokea
A nurse is caring for a client and her partner who have experienced a fetal death. Which of the following actions should the nurse take?
- A. Take photos of the newborn to give to the parents.
- B. Tell the parents that they can consider organ donations.
- C. Encourage the parents to avoid allowing older children to visit them in the hospital.
- D. Explain to the parents the need to name the newborn.
Correct Answer: A
Rationale: The correct answer is A because taking photos of the newborn allows the parents to create lasting memories and helps in the grieving process. It also validates the existence of the baby as a member of the family. Choice B may be insensitive as it might be too soon to discuss organ donation. Choice C may isolate the parents from their support system. Choice D may pressure the parents at a difficult time.
You may also like to solve these questions
An hour after delivery, the nurse instills erythromycin (Ilotycin) ointment into the eyes of a newborn. The main objective of the treatment is to prevent infection caused by which organism?
- A. Rubella
- B. Gonorrhea
- C. Syphilis
- D. Human immunodeficiency virus (HIV)
Correct Answer: B
Rationale: The correct answer is B: Gonorrhea. Erythromycin ointment is used to prevent ophthalmia neonatorum, a purulent conjunctivitis that can result from gonorrhea infection in newborns during passage through the birth canal. Gonorrhea is a common cause of this condition, and timely administration of erythromycin helps prevent its development. Rubella, syphilis, and HIV do not typically cause ophthalmia neonatorum, so choices A, C, and D are incorrect in this context.
A client is in the latent stage of labor. Which nursing intervention is most appropriate?
- A. Encourage the client to walk in the hall until membranes rupture
- B. Instruct the client to place her head on her chest and push with the contraction
- C. Teach the client to use the 'pant-blow' method of breathing
- D. Advise the client to eat a light meal consisting of carbohydrates
Correct Answer: A
Rationale: The correct answer is A because encouraging the client to walk in the hall can help progress labor by promoting movement and gravity, potentially aiding in cervical dilation and descent of the fetus. Walking may also provide comfort and distraction from labor discomfort. Choices B and C are incorrect as they are not appropriate actions during the latent stage of labor and can be harmful. Choice D is incorrect because it is not recommended to eat a meal during labor due to the risk of aspiration if anesthesia is needed.
A woman in the transition stage of labor is using paced breathing to relieve pain. She complains of blurred vision, numbness, and tingling of her hands and mouth. Which condition is indicated by these signs and symptoms?
- A. Anoxia
- B. Hyperventilation
- C. Anxiety
- D. Hypertension
Correct Answer: B
Rationale: The correct answer is B: Hyperventilation. The symptoms of blurred vision, numbness, and tingling in the hands and mouth are indicative of hyperventilation. During paced breathing, if the woman breathes too quickly or deeply, it can lead to a decrease in carbon dioxide levels in the blood, causing these symptoms. To address this, the woman should be guided to slow down her breathing and breathe into a paper bag to rebreathe some carbon dioxide. Anoxia (A) is a severe lack of oxygen, which would present with different symptoms. Anxiety (C) may cause similar symptoms but is not the primary issue here. Hypertension (D) does not typically lead to these specific symptoms.
Which conditions create a risk for uterine atony in the immediate postpartum period?
- A. Breastfeeding and delivery of an infant with chromosome defects
- B. Postterm birth and an amniotomy during labor
- C. Gestational diabetes and pregnancy-induced hypertension
- D. Multiparity and multiple gestation
Correct Answer: D
Rationale: Step-by-step rationale for why choice D is correct:
1. Multiparity: Women who have had multiple pregnancies are at higher risk for uterine atony due to uterine muscle fatigue.
2. Multiple gestation: The presence of more than one fetus puts increased demands on the uterus, increasing the risk of uterine atony.
Summary of why other choices are incorrect:
- A: Breastfeeding and chromosome defects are not directly linked to uterine atony.
- B: Postterm birth and amniotomy do not inherently increase the risk of uterine atony.
- C: Gestational diabetes and pregnancy-induced hypertension are not specific risk factors for uterine atony.
A 1-year-old receives routine health maintenance care at the pediatric clinic. The child receives an MMR immunization. The mother asks the nurse, 'When will my child get the next dose of MMR vaccine?' Which is the correct response by the nurse?
- A. In six months with the next DPT
- B. No further vaccination needed
- C. With the Hepatitis B series
- D. After the child is 10 years of age
Correct Answer: D
Rationale: A second MMR, often called a booster, will be needed when the child enters middle school at age eleven or twelve years of age. This ensures full immunity from the diseases covered by the MMR vaccine.