Nokea
A nurse is preparing staff education on the developmental stages and milestones in a normally developing fetus. Which information should be included?
- A. The testes at the inguinal ring descend to scrotum at 12 weeks.
- B. The bladder and urethra separate from the rectum at 12 weeks.
- C. The kidneys are in position at 16 weeks with typical shape and plan.
- D. The nostrils reopen and primitive respiratory-like movement begins at 24 weeks.
Correct Answer: C
Rationale: Kidneys reach their position by 16 weeks. Testicular descent occurs later (28-32 weeks), bladder-urethra separation by 8 weeks, and respiratory movements by 20-24 weeks.
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The nurse is caring for a client who is 38 weeks pregnant and plans to breastfeed. This is the client's first child, and she expresses concern about lactation. The nurse tells the client that which measures stimulate lactation? Select all that apply.
- A. breast massage
- B. frequent breastfeeding
- C. pumping breasts between feedings
- D. vigorous exercise one week after birth
- E. applying cold compresses to the breasts
Correct Answer: A,B,C
Rationale: Breast massage, frequent breastfeeding, and pumping stimulate milk production. Exercise and cold compresses do not.
Which instruction should the nurse include in the teaching plan for a client taking iron supplements to correct iron deficiency anemia?
- A. Eat a low-fiber diet.
- B. Limit the intake of fluids.
- C. Limit the intake of meat, fish, and poultry.
- D. Avoid taking the iron supplements with milk or antacids.
Correct Answer: D
Rationale: The client should avoid taking the iron supplements with milk or antacids because these items decrease the absorption of iron. The client should also avoid taking the iron with food, if possible. Finally, the client should take in sufficient fiber and fluids to prevent constipation as a side effect of iron therapy. The client should increase the intake of natural sources of iron, such as meats, fish, and poultry.
After a cleft lip repair, the nurse instructs the parents about cleaning of the lip repair site. The nurse should plan to use which solution when demonstrating this procedure to the parents?
- A. Tap water
- B. Sterile water
- C. Full-strength hydrogen peroxide
- D. Half-strength hydrogen peroxide
Correct Answer: B
Rationale: After cleft lip repair, the site is cleansed with sterile water using a cotton swab after feeding and as prescribed. Agency procedure should also be followed. The parents should be instructed to use a rolling motion starting at the suture line and rolling out. Tap water is not a sterile solution. Hydrogen peroxide may disrupt the integrity of the site.
The nurse is teaching a client with acute kidney injury to include proteins in the diet that are considered high quality or complete proteins. The nurse determines that the client needs further teaching if he indicates that which food item is considered high quality?
- A. Fish
- B. Eggs
- C. Chicken
- D. Broccoli
Correct Answer: D
Rationale: High-quality or complete proteins, which contain essential amino acids, come from animal sources like fish, eggs, and chicken. Broccoli, a plant-based source, provides low-quality or incomplete proteins, indicating the client's misunderstanding.
A clinic nurse providing home care instructions to an adolescent diagnosed with iron deficiency anemia concentrates on the administration of oral iron preparations. The nurse should tell the adolescent that it is best to take the iron with which liquid?
- A. Cola
- B. Soda
- C. Water
- D. Tomato juice
Correct Answer: D
Rationale: Iron should be administered with vitamin C-rich fluids because vitamin \mathrm{C enhances the absorption of the iron preparation. Tomato juice has a high ascorbic acid (vitamin C) content, whereas cola, soda, and water do not contain vitamin C.