Nokea
A nurse is caring for a postpartum person who is at risk for infection. What is the most important intervention to reduce the risk of infection?
- A. administer antibiotics
- B. apply a sterile dressing
- C. perform a vaginal exam
- D. administer pain relief
Correct Answer: A
Rationale: Correct Answer: A (administer antibiotics)
Rationale:
1. Administering antibiotics targets potential infection-causing pathogens directly.
2. Antibiotics help prevent the spread of infection within the body.
3. Prophylactic antibiotics are commonly used postpartum for high-risk individuals.
4. This intervention directly addresses the root cause of infection risk.
Summary:
B: Applying a sterile dressing is important for wound care but doesn't target systemic infection risk.
C: Performing a vaginal exam can introduce pathogens and increase infection risk.
D: Administering pain relief is important for comfort but doesn't directly reduce infection risk.
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What is the term for a nonstress test in which there are two or more fetal heart rate accelerations of 15 or more beats per minute (BPM) with fetal movement in a 20-minute period?
- A. Positive
- B. Negative
- C. Reactive
- D. Nonreactive
Correct Answer: C
Rationale: A nonstress test is considered reactive when there are at least two accelerations of 15 BPM or more in a 20-minute period, indicating fetal well-being.
The partner of a gravida accompanies her to her prenatal appointment. The nurse notes that the father of the baby has gained weight since she last saw him. Which of the following comments is most appropriate for the nurse to make to the father?
- A. I see that you are gaining weight right along with your partner.
- B. You and your partner will be able to go on a diet together after the baby is born.
- C. I can see that you are a bad influence on your partner’s eating habits.
- D. I am so glad to see that you are taking so much interest in your partner’s pregnancy.
Correct Answer: D
Rationale: This comment acknowledges the father's involvement positively without judgment. Commenting on weight gain or suggesting future diets could come across as insensitive or inappropriate.
A nurse is assisting a laboring person who is in the first stage of labor. What is the most appropriate intervention to promote relaxation and comfort?
- A. encourage ambulation
- B. administer pain medication
- C. provide distraction and breathing techniques
- D. offer relaxation techniques
Correct Answer: A
Rationale: The correct answer is A: encourage ambulation. Walking during the first stage of labor can help facilitate the descent of the fetus, promote optimal positioning, and enhance comfort by utilizing gravity to aid in the progression of labor. Ambulation also encourages blood circulation and may provide a distraction from discomfort. Administering pain medication (B) is not the initial intervention in promoting relaxation and comfort during early labor. Providing distraction and breathing techniques (C) may be beneficial, but ambulation is more effective in promoting relaxation. Offering relaxation techniques (D) is helpful, but encouraging movement through ambulation is a more active approach in easing discomfort and promoting relaxation during the first stage of labor.
During a vaginal birth, a birthing person experienced a second-degree perineal laceration. What is a characteristic of a second-degree laceration?
- A. It involves only the vaginal mucosa.
- B. It extends through the vaginal and perineal muscles.
- C. It is the least severe type of laceration.
- D. It does not require suturing.
Correct Answer: B
Rationale: The correct answer is B because a second-degree perineal laceration extends through the vaginal mucosa and perineal muscles. First, a second-degree laceration involves more than just the vaginal mucosa, as it also affects the perineal muscles. This type of laceration is more severe than a first-degree laceration, which only involves the vaginal mucosa. Second, due to the involvement of deeper structures like the perineal muscles, suturing is typically required to promote proper healing and prevent complications. Therefore, choice B is correct. Choices A and C are incorrect because a second-degree laceration involves more than just the vaginal mucosa and is not the least severe type of laceration. Choice D is incorrect because suturing is usually necessary for second-degree lacerations.
Which client consumed the most dairy servings in one day?
- A. Client 1
- B. Client 2
- C. Client 3
- D. Client 4
Correct Answer: B
Rationale: Client 2 consumed the highest number of dairy servings based on the provided quantities of yogurt, milk, cottage cheese, and hard cheese.