Nokea
A nurse is caring for a client who is at 30 weeks of gestation. The nurse should plan to immunize the client which of the following vaccinations? Select all the apply
- A. Varicella
- B. human papillomavirus
- C. Diphtheria - acellular pertussis
- D. inactivated influenza
- E. measles, mumps, and rubella
Correct Answer: C,D
Rationale: The correct answers are C (Diphtheria - acellular pertussis) and D (inactivated influenza) for a client at 30 weeks gestation. These vaccines are safe during pregnancy and provide protection to both the mother and the developing fetus. Diphtheria and pertussis can cause severe complications for newborns, so vaccinating the mother during pregnancy helps pass on immunity. Influenza vaccination is recommended to reduce the risk of severe illness in pregnant women and their babies. Choices A, B, and E are contraindicated during pregnancy due to potential harm to the fetus.
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A nurse is assessing a client who is 27 weeks of gestation and has pre eclampsia. Which of the following findings should the nurse report to the provider?
- A. Hemoglobin 14.8 g/dL
- B. Platelet count 60,000/ mm
- C. Creatine 0.8 mg/ dL
- D. Urine protein concentration 200 mg/24hr
Correct Answer: B
Rationale: The correct answer is B: Platelet count 60,000/ mm. In pre-eclampsia, a low platelet count indicates thrombocytopenia, a serious complication that can lead to bleeding. This finding should be reported promptly to the provider for further evaluation and management. A: Hemoglobin level is within normal range and not a priority in pre-eclampsia. C: Creatinine level is normal and not directly related to the complications of pre-eclampsia. D: Urine protein concentration is elevated, which is expected in pre-eclampsia and should be monitored, but not as urgent as low platelet count.
A nurse is providing teaching to the parents of a newborn about the plastibell circumcision technique. Which of the following? - p170-171 - postprocedure bottom of 170 and goes into top of 171.
- A. The plastibell will be removed 4 hours after the procedure
- B. Notify the provider is the end of your penis appears dark red
- C. Make sure the newborn's diaper is snug
- D. Yellow exudate will form at the surgical site in 24 hours
Correct Answer: D
Rationale: The correct answer is D. Yellow exudate forming at the surgical site in 24 hours is expected after plastibell circumcision due to the healing process. This exudate consists of dead cells and is a normal part of wound healing. It is important for the parents to be aware of this so they do not mistake it for an infection or abnormality.
Explanation for other choices:
A: The plastibell is not removed after 4 hours; it falls off on its own in about 5-10 days.
B: Dark red appearance at the end of the penis could indicate a potential issue, but immediate notification of the provider is not necessary.
C: Ensuring the newborn's diaper is snug is unrelated to the circumcision technique.
E, F, G: No information provided.
A nurse is providing teaching to a client who is 2 days postpartum and wants to continue using her diaphragm for contraception. Which of the following instructions should the nurse include?
- A. You should use an oil based vaginal lubricant when inserting your diaphragm
- B. You should store your diaphragm in sterile water after each use
- C. You should keep the diaphragm in place for at least 4 hours after intercourse
- D. You should have your provider refit you for a new diaphragm
Correct Answer: D
Rationale: The correct answer is D: You should have your provider refit you for a new diaphragm. This is important because postpartum changes, such as weight gain or loss, can affect the fit of the diaphragm. A proper fit is crucial for effective contraception. Storing the diaphragm in sterile water (B) is incorrect as it can damage the device. Using oil-based lubricants (A) is not recommended as they can weaken the diaphragm. Keeping the diaphragm in place for 4 hours after intercourse (C) is unnecessary and may increase the risk of infection.
A nurse is caring for a client who is 6 weeks of gestation and reports nausea and vomiting. Which of the following Recommendations should the nurse make?
- A. Avoid Eating snacks before bedtime
- B. Eat high-fat snack before getting out of bed
- C. Drink additional liquids with each meal
- D. Consume food served at cool temperatures
Correct Answer: D
Rationale: The correct answer is D: Consume food served at cool temperatures. This recommendation is based on the fact that pregnant women experiencing nausea and vomiting (commonly known as morning sickness) may find relief by consuming cold or cool foods, as they are less likely to trigger nausea compared to hot or warm foods. Cold foods also tend to have less of a strong smell, which can help reduce nausea. Avoiding snacks before bedtime (choice A) may not necessarily alleviate nausea in the morning. Eating high-fat snacks before getting out of bed (choice B) may worsen nausea. Drinking additional liquids with each meal (choice C) may not address the underlying cause of nausea and could potentially make it worse.
A nurse is planning care for a client who is pregnant and has HIV. Which of the following actions Should the nurse include in the plan of care?
- A. Use a fetal scalp electrode during labor and delivery
- B. Bathe the newborn before initiating skin to skin contact
- C. Instruct the client to stop taking the antiretroviral medication at 32 weeks of gestation
- D. Administer pneumococcal immunization to the newborn within 4 hours following birth
Correct Answer: B
Rationale: The correct answer is B: Bathe the newborn before initiating skin to skin contact. This action is crucial to reduce the risk of HIV transmission from the mother to the newborn. By bathing the newborn before skin-to-skin contact, the nurse can remove any potential HIV-infected fluids from the baby's skin, reducing the risk of transmission. This step helps to protect the newborn while still allowing for important bonding through skin-to-skin contact after bathing.
Choice A is incorrect as the use of a fetal scalp electrode during labor and delivery is unrelated to preventing HIV transmission from mother to newborn. Choice C is incorrect as stopping antiretroviral medication can significantly increase the risk of HIV transmission to the newborn. Choice D is incorrect as administering pneumococcal immunization is important but not within 4 hours following birth in the context of preventing HIV transmission.