Nokea
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.
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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 is caring for a 4-month-old infant with thrush (candidiasis) who is breastfed.
- A. "Administer the prescribed nystatin (Mycostatin) for 2 to 3 days after the lesions disappear."'
- B. "Place the infant on a soy-based formula to supplement breastfeeding until thrush is resolved."'
- C. "Discontinue breastfeeding and resume 48 hr after the last lesion disappears."'
- D. "Scrape off the white patches of thrush from the oral mucous membrane with a tongue depressor."'
Correct Answer: A
Rationale: Correct Answer: A
Rationale: Nystatin is an antifungal medication commonly used to treat thrush in infants. It is safe for infants and effective against Candida. The treatment should be continued for 2 to 3 days after the lesions disappear to ensure complete eradication of the infection. Discontinuing the medication prematurely can lead to a recurrence of thrush.
Summary of other choices:
B: Switching to a soy-based formula is unnecessary and does not address the thrush infection directly.
C: Discontinuing breastfeeding is not necessary and can disrupt the infant's feeding routine.
D: Scraping off the white patches can cause trauma to the oral mucosa and should be avoided.
A client delivered vaginally six hours ago. Which assessment finding can be interpreted as normal?
- A. Temperature 100.0 degrees F
- B. Blood pressure 140/90
- C. Respirations 10
- D. Pulse 90
Correct Answer: A
Rationale: The correct answer is A: Temperature 100.0 degrees F. This finding can be interpreted as normal because a slight increase in body temperature after childbirth is expected due to the physiological changes during labor. A temperature of 100.0 degrees F is within the normal range for postpartum women.
Rationale for why the other choices are incorrect:
B: Blood pressure 140/90 - This blood pressure reading is slightly elevated and may indicate hypertension, which would not be considered normal postpartum.
C: Respirations 10 - A respiratory rate of 10 is abnormally low and could indicate respiratory distress rather than normal postpartum recovery.
D: Pulse 90 - A pulse rate of 90 may be within normal limits, but it is not as indicative of normal postpartum recovery as a slightly elevated temperature would be.
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.
A 27-week gestation infant is taken to a newborn intensive care unit 150 miles away. Initially, which emotion should the nurse expect the mother to display after the transfer?
- A. Denial
- B. Frustration
- C. Guilt
- D. Anger
Correct Answer: C
Rationale: The correct answer is C: Guilt. The mother may feel responsible for the premature birth and subsequent transfer, leading to feelings of guilt. This is a common emotional response in such situations. Denial (A), frustration (B), and anger (D) may also be present, but guilt is the most likely initial emotion due to the perceived connection between the mother and the baby's health.