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: D
Rationale: Reporting the client's HIV status to the local health department is required by law to ensure proper public health monitoring and intervention.
You may also like to solve these questions
A nurse is assessing a client who is at 6 weeks of gestation and adheres to a vegan diet. Which of the following questions should the nurse ask to assess the client’s dietary intake?
- A. How much protein do you eat in a day?
- B. Are you taking a Vitamin C supplement?
- C. Have you considered eating shellfish?
- D. When was the last time you ate meat?
Correct Answer: A
Rationale: The correct answer is A: "How much protein do you eat in a day?" This question is important because as a vegan, the client may have a higher risk of protein deficiency due to the lack of animal protein in their diet. By asking about their protein intake, the nurse can assess if the client is meeting their protein needs for a healthy pregnancy.
Choice B, asking about a Vitamin C supplement, is incorrect as Vitamin C deficiency is not typically a concern for vegans and is not specifically related to gestational nutrition. Choice C, suggesting shellfish, is incorrect as it goes against the client's vegan dietary preferences. Choice D, asking about the last time the client ate meat, is also incorrect as it is not relevant to assessing their current dietary intake as a vegan.
A nurse is discussing fertility treatment options with a client and their partner. Which of the following nonpharmacological treatments should the nurse suggest?
- A. Use a lubricant during intercourse.
- B. Drink herbal tea two times daily.
- C. Maintain a healthy weight.
- D. Take daily hot baths.
Correct Answer: C
Rationale: Correct Answer: C - Maintain a healthy weight.
Rationale: Maintaining a healthy weight is crucial for fertility as obesity or being underweight can impact fertility. Excess body fat can disrupt hormone levels and ovulation, while being underweight can also affect reproductive function. By suggesting the couple to maintain a healthy weight, the nurse is promoting overall reproductive health.
Summary of other choices:
A: Using a lubricant during intercourse does not address the underlying fertility issues.
B: Drinking herbal tea may not have a direct impact on fertility and lacks scientific evidence.
D: Taking daily hot baths can actually decrease sperm count and affect fertility.
E, F, G: These options are not provided but would likely not be as relevant as maintaining a healthy weight.
A nurse is planning care for a client who is in labor and is requesting epidural anesthesia for pain control. Which of the following actions should the nurse include in the plan of care?
- A. Place the client in a supine position for 30 min following the first dose of anesthetic solution.
- B. Administer 1,000 mL of dextrose 5% in water prior to the first dose of anesthetic solution.
- C. Monitor the client's blood pressure every 5 min following the first dose of anesthetic solution.
- D. Ensure the client has been NPO 4 hr prior to the placement of the epidural and the first dose of anesthetic solution.
Correct Answer: C
Rationale: Monitoring the client's blood pressure every 5 minutes after the first dose of anesthetic solution is essential to detect and manage hypotension, a common side effect of epidural anesthesia.
A nurse is developing a plan of care for a newborn who is to undergo phototherapy for hyperbilirubinemia. Which of the following actions should the nurse include in the plan?
- A. Feed the newborn 1 oz of water every 4 hr.
- B. Apply lotion to the newborn's skin three times per day.
- C. Remove all clothing from the newborn except the diaper.
- D. Discontinue therapy if the newborn develops a rash.
Correct Answer: C
Rationale: The correct answer is C: Remove all clothing from the newborn except the diaper. During phototherapy, the newborn's skin needs to be exposed to the light to effectively treat hyperbilirubinemia. Removing all clothing allows maximum skin exposure. Option A is incorrect as water does not help with phototherapy. Option B is incorrect as lotion can interfere with the effectiveness of the therapy. Option D is incorrect as a rash is a common side effect of phototherapy and discontinuing it would hinder treatment.
A nurse manager on the labor and delivery unit is teaching a group of newly licensed nurses about maternal cytomegalovirus. Which of the following information should the nurse manager include in the teaching?
- A. Mothers will receive prophylactic treatment with acyclovir prior to delivery.
- B. Transmission can occur via the saliva and urine of the newborn.
- C. Lesions are visible on the mother’s genitalia.
- D. This infection requires that airborne precautions be initiated for the newborn.
Correct Answer: B
Rationale: The correct answer is B because cytomegalovirus can be transmitted through bodily fluids like saliva and urine. This is important for the nurses to understand as they care for newborns who may be infected. The other choices are incorrect because: A) Acyclovir is used for herpes simplex virus, not cytomegalovirus, C) Lesions are not typically visible with cytomegalovirus, D) Airborne precautions are not required for cytomegalovirus, and the other choices are not provided.