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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 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: The correct answer is D: Report the client's condition to the local health department. This is important to ensure proper monitoring, follow-up, and infection control measures. Reporting is necessary for contact tracing, prevention of transmission, and accessing appropriate support services. Administering penicillin G (A) is not indicated for HIV; the client needs antiretroviral therapy. Scheduling annual pelvic exams (B) is important for general health but not specific to HIV care. Waiting until after delivery to start HIV medication (C) is not recommended as timely treatment is crucial.
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Which of the following indicates whether the adolescent understands the teaching on requires further education?
- A. I should continue taking all my medications even if I don't show any symptoms.
- B. If I continue to get this type of infection, it can affect my ability to have kids in the future.
- C. I should go to the emergency department if my urine turns dark.
- D. As long as I keep my IUD, I don't need to use condoms.
- E. I'm more likely to get a sunburn while taking these medications.
Correct Answer: D
Rationale: [0, 0, 0]
A nurse is observing a new guardian caring for their crying newborn who is bottle feeding. Which of the following actions by the guardian should the nurse recognize as a positive parenting behavior?
- A. Lays the newborn across their lap and gently sways.
- B. Places the newborn in the crib in a prone position.
- C. Offers the newborn a pacifier dipped in formula.
- D. Prepares a bottle of formula mixed with rice cereal.
Correct Answer: A
Rationale: The correct answer is A because laying the newborn across the lap and gently swaying helps create a soothing and comforting environment for the baby. This position mimics the closeness and security of being held, promoting bonding and emotional connection between the guardian and the newborn. It also aids in digestion and reduces the risk of choking. Placing the newborn in the crib in a prone position (B) is unsafe as it increases the risk of sudden infant death syndrome. Offering a pacifier dipped in formula (C) may introduce unnecessary calories and disrupt feeding patterns. Preparing a bottle with rice cereal (D) can pose a choking hazard and is not recommended for newborns.
A nurse is performing a routine assessment on a client who is at 18 weeks of gestation. Which of the following findings should the nurse expect?
- A. Deep tendon reflexes 4+.
- B. Fundal height 14 cm.
- C. Blood pressure 142/94 mm Hg.
- D. FHR 152/min.
Correct Answer: D
Rationale: The correct answer is D: FHR 152/min. At 18 weeks gestation, the fetal heart rate (FHR) should be around 140-160 bpm, making a rate of 152/min within the expected range. This indicates normal fetal cardiac activity and development.
A: Deep tendon reflexes are not typically assessed during routine prenatal visits and are not related to gestational age.
B: Fundal height at 18 weeks should be around the level of the umbilicus, which is closer to 20 cm, not 14 cm.
C: Blood pressure of 142/94 mm Hg is elevated and indicates hypertension, which is not expected at 18 weeks gestation.
E, F, G: No other options provided.
A nurse is assessing a newborn following a circumcision. Which of the following findings should the nurse identify as an indication that the newborn is experiencing pain?
- A. Decreased heart rate.
- B. Chin quivering.
- C. Pinpoint pupils.
- D. Slowed respirations.
Correct Answer: B
Rationale: The correct answer is B: Chin quivering. Pain assessment in newborns can be challenging due to their limited ability to communicate. Chin quivering is a common behavioral indicator of pain in newborns. It is a subtle sign of distress and discomfort. Other choices such as decreased heart rate (A), pinpoint pupils (C), and slowed respirations (D) are not reliable indicators of pain in newborns. Decreased heart rate can indicate relaxation, pinpoint pupils are more indicative of opioid use, and slowed respirations might be a sign of sleepiness or relaxation rather than pain.
A nurse is caring for a client who becomes unresponsive upon delivery of the placenta. Which of the following actions should the nurse take first?
- A. Determine respiratory function.
- B. Increase the IV fluid rate.
- C. Access emergency medications from the cart.
- D. Collect a maternal blood sample for coagulopathy studies.
Correct Answer: A
Rationale: The correct action for the nurse to take first is to determine respiratory function (Choice A). This is crucial as an unresponsive client may have compromised breathing which can lead to serious consequences such as hypoxia or respiratory arrest. Assessing respiratory function will help the nurse identify any immediate life-threatening issues and initiate appropriate interventions. Increasing IV fluid rate (Choice B) may be important later but is not the priority in this situation. Accessing emergency medications (Choice C) and collecting a maternal blood sample (Choice D) can also be important but do not address the immediate need to ensure adequate oxygenation. By prioritizing respiratory function assessment, the nurse can quickly address the most critical aspect of the client's care.