Nokea
A nurse is performing a routine physical examination on an adolescent client who asks, 'Why do I have to use a condom if my girlfriend is on the pill?' Which of the following is the most appropriate response by the nurse?
- A. You need to use two forms of birth control so if one fails you have a second form of protection against pregnancy.
- B. Using a condom allows you to share the responsibility for birth control.
- C. Oral contraceptives are less than 99 percent effective in adolescents. Therefore, a second form of contraception is needed.
- D. Oral contraceptives are highly effective in preventing pregnancy but do not prevent sexually transmitted diseases.
Correct Answer: D
Rationale: The correct answer is D. The nurse should explain that while oral contraceptives are highly effective in preventing pregnancy, they do not protect against sexually transmitted diseases (STDs). This is important because even if the girlfriend is on the pill, using a condom is necessary to prevent STD transmission. Adolescents are at higher risk for STDs, so it is crucial to emphasize the importance of dual protection. Choice A is incorrect as it does not specifically address the risk of STD transmission. Choice B is incorrect because it focuses on shared responsibility rather than the health implications of using a condom. Choice C is incorrect as it emphasizes the effectiveness of oral contraceptives rather than the need for STD protection.
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The nursery nurse delays the first bottle feeding of a newborn. Which is the most common reason for the nurse's actions? The infant has:
- A. a blood glucose of 45 gm/dL
- B. a respiratory rate above 60
- C. blue hands and feet
- D. a heart murmur
Correct Answer: B
Rationale: The correct answer is B: a respiratory rate above 60. The nurse delays feeding because a high respiratory rate may indicate respiratory distress, making feeding unsafe. Feeding can lead to aspiration in infants with respiratory issues. A blood glucose of 45 gm/dL (choice A) is low but not typically a reason to delay feeding. Blue hands and feet (choice C) may indicate poor circulation, but it's not a common reason to delay feeding. A heart murmur (choice D) doesn't directly impact feeding safety.
A 15-year-old client visits the clinic to get medical clearance to play a sport.
- A. "I will avoid showering at the gym."'
- B. "I can apply an antifungal cream daily."'
- C. "I should wear dark-colored socks."'
- D. "I should wear well-ventilated shoes."'
Correct Answer: D
Rationale: The correct answer is D: "I should wear well-ventilated shoes." This is because well-ventilated shoes help prevent fungal infections by keeping the feet dry and reducing moisture buildup, which is crucial for active individuals like athletes. Choice A is incorrect as avoiding showering at the gym is not a practical solution for preventing fungal infections. Choice B, applying antifungal cream daily, is reactive rather than preventive. Choice C, wearing dark-colored socks, does not directly address the issue of moisture and ventilation.
Which preoperative nursing interventions should be included for a client who is scheduled to have an emergency cesarean birth?
- A. Monitor oxygen saturation and administer pain medication.
- B. Assess vital signs every 15 minutes and instruct the client about postoperative care. Alleviate anxiety and insert an indwelling catheter.
- C. Perform a sterile vaginal examination and assess breath sounds.
- D. 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.
Correct Answer: B
Rationale: The correct answer is B. Assessing vital signs every 15 minutes is crucial in an emergency cesarean birth to monitor the client's condition. Instructing the client about postoperative care ensures they are well-prepared. Alleviating anxiety is important for the client's emotional well-being. Inserting an indwelling catheter is also necessary for bladder emptying to prevent injury during surgery. Choice A is incorrect because oxygen saturation monitoring is not typically a preoperative intervention for a cesarean birth, and administering pain medication may not be necessary preoperatively. Choice C is incorrect as a sterile vaginal examination is not indicated before a cesarean birth, and assessing breath sounds does not directly relate to preoperative care for this procedure. Choice D is incorrect because although anxiety management and indwelling catheter insertion are important, the rationale provided is not directly related to preoperative care for a cesarean birth.
During active labor, after a sudden slowing of the fetal heart rate, the nurse assesses the woman's perineum and observes a prolapsed cord. Which nursing action is most appropriate?
- A. Hold the presenting part away from the cord
- B. Insert a scalp electrode for an internal fetal monitor
- C. Place the client in reverse Trendelenburg position
- D. Cover the cord with a dry,sterile gauze
Correct Answer: A
Rationale: The correct answer is A: Hold the presenting part away from the cord. This action helps relieve pressure on the cord, preventing further compromise of blood flow to the fetus. It is crucial to maintain fetal perfusion. Choice B (Insert a scalp electrode) and D (Cover the cord with gauze) are not appropriate as they do not address the immediate risk of cord compression. Choice C (Reverse Trendelenburg) may worsen the prolapse by shifting the presenting part higher.
A nurse is checking children at an orthopedic outpatient setting. Which of the following should the nurse expect to see as manifestations of scoliosis?
- A. Pain and an exaggerated lumbar curvature'
- B. Uneven shoulder heights and poorly fitting slacks'
- C. Tenderness and swelling of the spine'
- D. Limited range of motion of the back and a limp'
Correct Answer: B
Rationale: The correct answer is B. Uneven shoulder heights and poorly fitting slacks are common manifestations of scoliosis because the condition causes an abnormal curvature of the spine, leading to uneven shoulders and hips. Pain and exaggerated lumbar curvature (choice A) are not specific manifestations of scoliosis. Tenderness and swelling of the spine (choice C) could indicate other conditions like infection or inflammation, not necessarily scoliosis. Limited range of motion of the back and a limp (choice D) are more indicative of musculoskeletal injuries or disorders, not scoliosis.