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 they will start medication for HIV immediately after delivery.
- D. Report the client's condition to the local health department.
Correct Answer: C
Rationale: The correct answer is C: Tell the client they will start medication for HIV immediately after delivery. This is because starting HIV medication immediately after delivery helps prevent vertical transmission of the virus to the baby. Administering penicillin G (choice A) is not indicated for HIV treatment. Instructing the client to schedule an annual pelvic examination (choice B) is important but not the priority in this case. Reporting the client's condition to the local health department (choice D) may be necessary for public health surveillance, but it is not the immediate action required for the client's care in this situation.
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A nurse is assessing a newborn who was born postterm. Which of the following findings should the nurse expect?
- A. Large deposits of subcutaneous fat
- B. Thin covering of fine hair on shoulders and back
- C. Nails extending over tips of fingers
- D. Pale, translucent skin
Correct Answer: C
Rationale: The correct answer is C: Nails extending over tips of fingers. This is expected in postterm newborns due to prolonged intrauterine growth. The nails continue to grow in utero, leading to longer nails at birth. Large deposits of subcutaneous fat (option A) are typically seen in term newborns, not postterm. Thin covering of fine hair on shoulders and back (option B) is known as lanugo, which is more common in premature infants. Pale, translucent skin (option D) is also more common in premature infants due to decreased subcutaneous fat. Therefore, the correct answer is C, nails extending over tips of fingers, as it is a characteristic finding in postterm newborns.
Which of the following is a potential legal issue related to informed consent in maternal and newborn healthcare?
- A. Failure to obtain informed consent
- B. Lack of understanding by the patient or family
- C. Coercion or duress in obtaining consent
- D. All of the above
Correct Answer: D
Rationale: The correct answer is D: All of the above. This is because failure to obtain informed consent violates patient autonomy and can lead to legal consequences. Lack of understanding by the patient or family can result in invalid consent. Coercion or duress in obtaining consent undermines voluntary decision-making. Therefore, all three options represent potential legal issues related to informed consent in maternal and newborn healthcare.
What is the recommended method of screening for syphilis during pregnancy?
- A. Venereal disease research laboratory (VDRL) test
- B. Rapid plasma reagin (RPR) test
- C. Fluorescent treponemal antibody absorption (FTA-ABS) test
- D. All of the above
Correct Answer: D
Rationale: Screening for syphilis during pregnancy can involve the VDRL, RPR, or FTA-ABS tests.
A nurse is caring for a client who is at 33 weeks of gestation following an amniocentesis. The nurse should monitor the client for which of the following complications?
- A. Vomiting
- B. Hypertension
- C. Epigastric pain
- D. Contractions
Correct Answer: D
Rationale: Contractions can indicate preterm labor, a potential complication following amniocentesis. Vomiting, hypertension, and epigastric pain are less directly related to the procedure.
Which of the following is a potential complication of neonatal sepsis?
- A. Hypoglycemia
- B. Respiratory distress syndrome
- C. Meningitis
- D. All of the above
Correct Answer: D
Rationale: The correct answer is D: All of the above. Neonatal sepsis can lead to various complications. Hypoglycemia may occur due to the body's response to infection. Respiratory distress syndrome can develop as a result of sepsis-induced lung damage. Meningitis is a serious complication of sepsis, affecting the brain and spinal cord. Choosing D is correct because sepsis can affect multiple systems, resulting in these varied complications. Choices A, B, and C are incorrect because they represent individual complications of sepsis, whereas D encompasses all the potential complications that can arise from neonatal sepsis.