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A nurse is discussing nutrition with an adolescent who is pregnant.
- A. "I told my daughter that any calories ingested are a source of energy and nutrition."'
- B. "I try to provide foods with an increased amount of calcium,protein and iron."'
- C. "I encourage between-meal snacks that are complex carbohydrates and fruits."'
- D. "I have planned meals and snacks for additional calories in the second and third trimester."'
Correct Answer: A
Rationale: Step 1: A is correct because it emphasizes the importance of calorie intake for energy and nutrition during pregnancy.
Step 2: Adolescents have higher calorie needs during pregnancy, making this advice crucial.
Step 3: B focuses on specific nutrients but doesn't address overall calorie intake.
Step 4: C mentions healthy snacks but doesn't emphasize the importance of calories.
Step 5: D mentions additional calories but lacks the focus on all calories being essential.
Step 6: A provides a comprehensive approach to nutrition during pregnancy, making it the correct choice.
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During the postpartum period, a hospitalized client complains of discomfort related to her episiotomy. The nurse assigns the diagnosis of 'pain related to perineal sutures.' Which nursing intervention is most appropriate during the first 24 hours following an episiotomy?
- A. Instruct the client to use petroleum jelly on the episiotomy after voiding.
- B. Encourage the client to practice Kegel exercises.
- C. Advise the client to take a warm sitz bath every four hours.
- D. Apply ice packs to the perineum.
Correct Answer: D
Rationale: The correct answer is D: Apply ice packs to the perineum. Ice packs help reduce swelling and provide numbing relief, which can help alleviate pain in the immediate postpartum period. Applying ice packs during the first 24 hours can also promote vasoconstriction, reducing the risk of bleeding and infection.
Incorrect options:
A: Using petroleum jelly can increase the risk of infection and hinder wound healing.
B: Kegel exercises are beneficial for pelvic floor strengthening but are not the most appropriate intervention for immediate pain relief.
C: While sitz baths can be soothing, they may not be suitable within the first 24 hours post-episiotomy as they can increase blood flow and potentially worsen swelling.
Overall, ice packs are the most effective and appropriate intervention for pain management in the immediate postpartum period.
A nurse provided discharge teaching to new parents on how to care for their newborn following circumcision. Which of the following statements by the parents indicates the need for further clarification?
- A. I should not remove the yellow exudate on the end of the penis.
- B. I will clean his penis with each diaper change.
- C. The circumcision will heal completely within a couple of weeks.
- D. I can give him a tub bath in two days.
Correct Answer: D
Rationale: The correct answer is D: "I can give him a tub bath in two days." This statement indicates the need for further clarification because newborns who have undergone circumcision should avoid submerging the area in water until it is fully healed to prevent infection. Tub baths should be avoided until the circumcision site has completely healed, which usually takes about 7-10 days. It is important to keep the area clean and dry during this time to promote healing.
Explanation for other choices:
A: "I should not remove the yellow exudate on the end of the penis." - Correct, as it is normal and part of the healing process.
B: "I will clean his penis with each diaper change." - Correct, as keeping the area clean helps prevent infection.
C: "The circumcision will heal completely within a couple of weeks." - Correct, as the healing process typically takes around 1-2 weeks.
A nurse is reinforcing teaching with the parents of an infant diagnosed with recurrent otitis media. Which of the following is appropriate teaching to include?
- A. Give the child an over-the-counter antihistamine when the symptoms begin.
- B. Hold the child in an upright position while feeding.
- C. Talk with the primary health care provider about performing a tonsillectomy.
- D. Apply a warm compress over the affected ear to provide comfort.
Correct Answer: B
Rationale: The correct answer is B: Hold the child in an upright position while feeding. This is important because feeding the infant in an upright position can help prevent reflux of milk into the Eustachian tube, reducing the risk of otitis media. This position helps to promote proper drainage and ventilation of the middle ear, decreasing the likelihood of infection.
Incorrect answers:
A: Giving the child an over-the-counter antihistamine is not appropriate for otitis media, as it is typically caused by bacterial infection, not allergies.
C: Tonsillectomy is not a first-line treatment for otitis media. It is usually considered if the child has recurrent tonsillitis, not otitis media.
D: Applying a warm compress over the affected ear may provide comfort but does not address the underlying cause or prevention of otitis media.
A nurse smells an odor identified as marijuana coming from a room. Which of the following client findings would confirm inhalation of the substance?
- A. Poor coordination, red eyes, and euphoria
- B. Slurred speech, confusion, and combativeness
- C. Loss of consciousness, respiratory depression, and coma
- D. Hypertension, tachycardia, and hyperflexia
Correct Answer: A
Rationale: The correct answer is A because poor coordination, red eyes, and euphoria are classic signs of marijuana inhalation. Poor coordination is a common effect due to impairment of motor skills. Red eyes result from vasodilation caused by marijuana. Euphoria is a psychological effect of the drug. Slurred speech, confusion, and combativeness (Option B) are more indicative of alcohol or sedative use. Loss of consciousness, respiratory depression, and coma (Option C) are severe symptoms more likely associated with opioid or sedative overdose. Hypertension, tachycardia, and hyperflexia (Option D) are not typically seen with marijuana use; they are more consistent with stimulant use.
A woman in the transition stage of labor is using paced breathing to relieve pain. She complains of blurred vision, numbness, and tingling of her hands and mouth. Which condition is indicated by these signs and symptoms?
- A. Anoxia
- B. Hyperventilation
- C. Anxiety
- D. Hypertension
Correct Answer: B
Rationale: The correct answer is B: Hyperventilation. The symptoms of blurred vision, numbness, and tingling in the hands and mouth are indicative of hyperventilation. During paced breathing, if the woman breathes too quickly or deeply, it can lead to a decrease in carbon dioxide levels in the blood, causing these symptoms. To address this, the woman should be guided to slow down her breathing and breathe into a paper bag to rebreathe some carbon dioxide. Anoxia (A) is a severe lack of oxygen, which would present with different symptoms. Anxiety (C) may cause similar symptoms but is not the primary issue here. Hypertension (D) does not typically lead to these specific symptoms.