Nokea
A nurse is performing a physical assessment of a newborn. Which of the following clinical findings should the nurse expect? (Select all that apply).
- A. Heart Rate 154/min
- B. Axillary temperature 96.8 F
- C. Respiratory rate 58/min
- D. Length 43 cm (16.9in)
Correct Answer: A,B,C,D
Rationale: The correct answer is A, B, C, and D.
1. Heart rate of 154/min is expected in a newborn, indicating normal cardiac function.
2. Axillary temperature of 96.8 F is within the normal range for a newborn.
3. Respiratory rate of 58/min is expected due to the newborn's immature respiratory system.
4. Length of 43 cm (16.9 in) falls within the normal range for a newborn's size.
Incorrect choices are not applicable due to lack of details, but in general, incorrect options would have included values outside the normal range for a newborn's physical assessment.
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A multiparous woman with a history of all vaginal births is admitted to the hospital in labor. After several hours, the client's labor has not progressed and she is getting tired and restless. The decision is made to proceed with cesarean delivery. The nurse recognizes the client's knowledge deficit regarding the surgical delivery and care after birth. Which is the appropriate expected outcome for correction of the client's knowledge deficit? The client will:
- A. Demonstrate appropriate coping mechanisms needed to get through the surgery.
- B. Accept that the type of delivery will not affect the bonding with the baby.
- C. Verbalize understanding about the reason for the unplanned surgery.
- D. Demonstrate decreased anxiety and fear of the unknown.
Correct Answer: C
Rationale: The correct answer is C: Verbalize understanding about the reason for the unplanned surgery. This outcome focuses on the client understanding why the cesarean delivery is necessary, which is crucial for informed decision-making and reducing anxiety. It shows the client comprehends the situation, which is important for her emotional well-being and cooperation during the procedure and postpartum period. Option A is incorrect because coping mechanisms are important but not directly related to knowledge deficit correction. Option B is incorrect as it does not address the client's knowledge deficit but rather focuses on emotional aspects. Option D is incorrect as it addresses anxiety and fear but not the underlying issue of knowledge deficit.
A client in preterm labor is admitted to the hospital. Which classification of drugs should the nurse anticipate administering?
- A. Tocolytics
- B. Anticonvulsants
- C. Glucocorticoids
- D. Anti-infective
Correct Answer: A
Rationale: The correct answer is A: Tocolytics. Tocolytics are drugs used to inhibit uterine contractions and delay preterm labor. They help prevent premature birth and allow time for other interventions. Anticonvulsants (B) are used to treat seizures, not preterm labor. Glucocorticoids (C) are given to enhance fetal lung maturity in preterm labor, but do not inhibit contractions. Anti-infectives (D) are used to treat infections, not preterm labor. Therefore, tocolytics are the most appropriate choice in this scenario.
A nurse is reviewing discharge teaching with the parents of a child who has pediculosis.Which of the following should the nurse include in the teaching?
- A. "Children can share scarves and coats ,but not hats or combs."'
- B. "Household pets can carry and transmit lice to people."'
- C. "After washing clothing,hang clothes outside to dry."'
- D. "Seal nonwashable items in plastic bags for 14 days."'
Correct Answer: D
Rationale: The correct answer is D. The nurse should include sealing nonwashable items in plastic bags for 14 days in the teaching for pediculosis. This is important to prevent reinfestation as lice can survive for up to 48 hours without a host. By sealing items in plastic bags for 14 days, any remaining lice or eggs will die off.
Choice A is incorrect because lice can be transmitted through shared hats and combs, not just scarves and coats. Choice B is incorrect as lice do not live on household pets. Choice C is incorrect as hanging clothes outside will not effectively eliminate lice.
Which preoperative nursing interventions should be included for a client who is scheduled to have an emergency cesarean birth?
- A. Monitoring O2 saturations and administering pain medications are postoperative interventions.
- B. Taking vital signs every 15 minutes is a postoperative intervention. Instructing the client regarding breathing exercises is not appropriate in a crisis situation when the client's anxiety is high, because information would probably not be retained. In an emergency, there is time only for essential interventions.
- C. Because this is an emergency, surgery must be performed quickly. Anxiety of the client and the family will be high. Inserting an indwelling catheter helps to keep the bladder empty and free from injury when the incision is made.
- D. The nurse should have assessed breath sounds upon admission. Breath sounds are important if the client is to receive general anesthesia, but the anesthesiologist will be listening to breath sounds in surgery in that case.
Correct Answer: C
Rationale: The correct answer is C because in an emergency cesarean birth, surgery must be performed quickly to ensure the safety of the mother and baby. Inserting an indwelling catheter is crucial to keep the bladder empty and prevent injury during the incision. This intervention helps maintain a sterile field and reduces the risk of infection. Additionally, a full bladder can impede the progress of surgery. Monitoring O2 saturations and administering pain medications (A) are postoperative interventions and not relevant in the preoperative phase. Taking vital signs every 15 minutes (B) is more appropriate for the postoperative period. Assessing breath sounds (D) is important but typically done by the anesthesiologist during surgery. Instructing the client about breathing exercises (B) may not be effective in an emergency situation where immediate interventions are necessary.
A 27-week gestation infant is taken to a newborn intensive care unit 150 miles away. Initially, which emotion should the nurse expect the mother to display after the transfer?
- A. Denial
- B. Frustration
- C. Guilt
- D. Anger
Correct Answer: C
Rationale: The correct answer is C: Guilt. The mother may feel responsible for the premature birth and subsequent transfer, leading to feelings of guilt. This is a common emotional response in such situations. Denial (A), frustration (B), and anger (D) may also be present, but guilt is the most likely initial emotion due to the perceived connection between the mother and the baby's health.