Nokea
A nurse is planning care for a client who is pregnant and has HIV.
- A. Use a fetal scalp electrode during labor and delivery
- B. Bathe the newborn before initiating skin-to-skin contact
- C. Instruct the client to stop taking the antiretroviral medication at 32 weeks of gestation
- D. Administer pneumococcal immunization to the newborn within 4 hours following birth
Correct Answer: B
Rationale: The correct answer is B: Bathe the newborn before initiating skin-to-skin contact. This is because bathing the newborn before skin-to-skin contact helps reduce the risk of HIV transmission from mother to baby. HIV can be present in maternal blood and other fluids, and washing the newborn can decrease the viral load on the baby's skin. Initiating skin-to-skin contact without bathing first may increase the risk of transmission.
Choice A is incorrect because using a fetal scalp electrode during labor and delivery is unrelated to preventing HIV transmission from mother to baby. Choice C is incorrect as stopping antiretroviral medication can be harmful to both the mother and the baby's health. Choice D is incorrect as pneumococcal immunization is not recommended within 4 hours following birth and is not directly related to HIV transmission prevention.
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A nurse in a woman’s health clinic is obtaining a health history from a client. Which of the following findings should the nurse identify as increasing the client’s risk for developing pelvic inflammatory disease (PID)?
- A. Recurrent Cystitis
- B. Frequent Alcohol Use
- C. Use of Oral Contraceptives
- D. Chlamydia Infection
Correct Answer: D
Rationale: The correct answer is D: Chlamydia Infection. Chlamydia is a common sexually transmitted infection that can lead to PID if left untreated. The bacteria can ascend from the cervix to the upper genital tract, causing inflammation and scarring. This increases the risk of PID. Recurrent Cystitis (A) is a urinary tract infection and not directly related to PID. Frequent Alcohol Use (B) does not directly increase the risk of developing PID. Use of Oral Contraceptives (C) actually decreases the risk of PID by reducing the chances of getting sexually transmitted infections.
A nurse is caring for a client who has placenta previa. Which of the following findings should the nurse expect?
- A. Firm rigid abdomen
- B. Painless vaginal bleeding
- C. Uterine hypertonicity
- D. Persistent headache
Correct Answer: B
Rationale: The correct answer is B: Painless vaginal bleeding. In placenta previa, the placenta partially or completely covers the cervix, leading to painless vaginal bleeding. This occurs due to separation of the placenta from the uterine wall. A firm rigid abdomen (A) is more indicative of abruptio placentae. Uterine hypertonicity (C) is seen in conditions like uterine rupture, not placenta previa. Persistent headache (D) is not typically associated with placenta previa.
A nurse is planning care for a newborn who is scheduled to start phototherapy using a lamp. Which of the following actions should the nurse include in the plan?
- A. Apply a thin layer of lotion to the newborn skin every 8 hrs.
- B. Give the newborn 1oz of glucose water every 4 hrs
- C. Ensure the newborn eyes are closed beneath the shield.
- D. Dress the newborn in a thin layer of clothing during therapy
Correct Answer: C
Rationale: Rationale: Choice C is correct because ensuring the newborn's eyes are closed beneath the shield during phototherapy prevents potential eye damage from the bright light. Closing the eyes protects the delicate eye tissues from exposure to the intense light. This action is crucial in preventing eye injury and promoting the safety and well-being of the newborn.
Incorrect Choices:
A: Applying lotion to the skin can intensify the effects of the light and should be avoided.
B: Giving glucose water is unnecessary and not related to phototherapy.
D: Dressing the newborn in clothing can interfere with the effectiveness of the light therapy.
A charge nurse is teaching a group of staff nurses about fetal monitoring during labor. Which of the following findings should the charge nurse instruct the staff members to report to the provider?
- A. Contraction durations of 95 to 100 seconds
- B. Contraction frequency of 2 to 3 min apart
- C. Absent early deceleration of fetal heart rate
- D. Fetal heart rate is 140/min
Correct Answer: A
Rationale: The correct answer is A: Contraction durations of 95 to 100 seconds. This is an abnormal finding as typical contraction durations should be around 60-90 seconds. Prolonged contractions can lead to decreased fetal oxygenation and distress. Choice B is incorrect as contractions 2-3 minutes apart are within the normal range. Choice C is incorrect as absent early deceleration is a reassuring sign of fetal well-being. Choice D is incorrect as a fetal heart rate of 140/min is within the normal range of 110-160/min.
A nurse is providing teaching to a client who is 2 days postpartum and wants to continue using her diaphragm for contraception.
- A. You should use an oil-based vaginal lubricant when inserting your diaphragm
- B. You should store your diaphragm in sterile water after each use
- C. You should keep the diaphragm in place for at least 4 hours after intercourse
- D. You should have your provider refit you for a new diaphragm
Correct Answer: D
Rationale: The correct answer is D: You should have your provider refit you for a new diaphragm. After childbirth, the size and shape of the cervix and vaginal canal may change, affecting the fit of the diaphragm. It is essential to have a healthcare provider assess and refit the diaphragm to ensure proper contraception.
Incorrect answers:
A: Using oil-based vaginal lubricant can degrade latex diaphragms, leading to breakage.
B: Storing the diaphragm in sterile water can damage the latex material and increase the risk of infection.
C: Keeping the diaphragm in place for a specific time after intercourse is not necessary and can increase the risk of toxic shock syndrome.
E: Not applicable.
F: Not applicable.
G: Not applicable.