Nokea
A nurse is doing genetic counseling with a couple. give to a client undergoing a mastectomy? The mother has Down syndrome and the father
- A. Tylenol should be avoided after surgery. has no chromosomal abnormalities. What is the
- B. The affected arm should remain in a sling for chance of their offspring being affected by this 4 weeks. disorder?
- C. The client should expect the affected arm to be
- D. 25%
Correct Answer: D
Rationale: When a woman with Down syndrome (trisomy 21) has a child with a man who does not have any chromosomal abnormalities, the chance of their offspring having Down syndrome is 25%. This is because the mother can only pass on one copy of the extra chromosome 21 to her child, resulting in a 50% chance of passing it on. However, since the father does not have an extra chromosome 21 to contribute, the overall chance of the child having Down syndrome is reduced to 25%.
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The nurse is preparing a client for cesarean delivery. What is the priority nursing action?
- A. Obtain baseline vital signs.
- B. Insert an indwelling urinary catheter.
- C. Verify signed informed consent.
- D. Administer prophylactic antibiotics.
Correct Answer: C
Rationale: Ensuring informed consent is signed is a priority before any surgical procedure.
A 17-year-old patient receives emergency contraception in a clinic. What is the priority nursing education for this patient at this time?
- A. The need for further contraception because the emergency contraception is only temporary
- B. The need to protect herself from STIs
- C. The need to come back in for a pelvic examination 1 week after taking the medication
- D. The need to drink plenty of fluids while on this medication
Correct Answer: A
Rationale: The patient should be informed that emergency contraception is a temporary measure and they need a long-term contraceptive plan. Choice B, while important for overall sexual health, is not the priority immediately after administering emergency contraception. Choice C is not necessary unless there are complications or a follow-up consultation is needed. Choice D about drinking fluids is unnecessary and not specific to the effectiveness of emergency contraception.
The nurse is caring for a client whose labor is being augmented with Pitocin. He or she recognizes that Pitocin should be stopped immediately if there is evidence of what?
- A. Fetal HR 180 without sense of variability
- B. Rupture of amniotic membrane
- C. Client needs to void
- D. Uterine contractions q8-10 minutes
Correct Answer: A
Rationale: Pitocin is a medication commonly used to induce or augment labor by stimulating uterine contractions. It is critical for the nurse to monitor the client closely for potential adverse effects. Fetal distress is a serious concern when Pitocin is being administered. A fetal heart rate of 180 beats per minute without variability may indicate fetal distress due to uteroplacental insufficiency. This is a sign of fetal hypoxia and warrants immediate intervention, including stopping the infusion of Pitocin, repositioning the mother, administering oxygen, and notifying the healthcare provider. It is crucial for the nurse to act promptly to ensure the safety and well-being of both the fetus and the mother.
The nurse is caring for a client who just had a cesarean delivery. What is the priority nursing action?
- A. Assess the surgical site.
- B. Monitor for signs of infection.
- C. Assess the uterine fundus for firmness.
- D. Encourage early ambulation.
Correct Answer: C
Rationale: Assessing fundal firmness helps detect uterine atony and prevent postpartum hemorrhage after delivery.
What does the nurse know about the definition of a family?
- A. Families are made up of couples with biological children.
- B. Families are created through marriage or birth.
- C. Families can be blended but are not called families.
- D. Families are made of kinships defined by the family.
Correct Answer: D
Rationale: Families are diverse and defined by the individuals involved, not limited to traditional structures.