Nokea
A nurse is providing home care to a home-bound patient treated with intravenous (IV) therapy and enteral nutrition. What is the home health nurse’s primary objective?
- A. Screening
- B. Education
- C. Dependence
- D. Counseling
Correct Answer: B
Rationale: Health promotion and education are traditionally the primary objectives of home care, yet at present most patients receive home care because they need nursing care. Screening is preventive care. The home health nurse focuses on patient and family independence. Counseling is through psychiatric care.
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A neonate in the nursery, whose mother had no prenatal care, has been diagnosed with macrosomia. For which of the following signs/symptoms should the nurse carefully monitor this baby?
- A. Jaundice.
- B. Jitters.
- C. Blepharitis.
- D. Strabismus.
Correct Answer: B
Rationale: Macrosomic babies are at risk for hypoglycemia, which can present as jitteriness.
A patient in her third trimester of pregnancy is asking about safe travel. Which statement should the nurse provide regarding safe travel during pregnancy?
- A. Only travel by car during pregnancy.'
- B. Avoid use of the seat belt during the third trimester.'
- C. You can travel by plane until your 38th week of gestation.'
- D. If you are traveling by car stop to walk every 1 to 2 hours.'
Correct Answer: D
Rationale: The correct answer is D: "If you are traveling by car, stop to walk every 1 to 2 hours." This is the best advice because it promotes circulation and reduces the risk of blood clots during long car rides. Walking helps prevent stiffness and discomfort.
A: "Only travel by car during pregnancy" is incorrect because other modes of transportation can be safe as well.
B: "Avoid use of the seat belt during the third trimester" is incorrect as wearing a seat belt is crucial for the safety of both the mother and the baby in case of an accident.
C: "You can travel by plane until your 38th week of gestation" is incorrect as most airlines have restrictions on flying after 36 weeks due to the risk of preterm labor.
The nurse is caring for a pregnant client who was sent to the hospital for a biophysical profile. She is 37 weeks gestation with her second child, has gestational diabetes, and complains of decreased fetal movement for the last 24 hours. Which action should the nurse take first?
- A. Perform vital signs
- B. Call physician
- C. Perform glucose
- D. Place on fetal monitor
Correct Answer: D
Rationale: The correct answer is D: Place on fetal monitor. This action is crucial to assess the fetal well-being and monitor the baby's heart rate and movements. It helps in determining if the baby is in distress and requires immediate intervention. Performing vital signs (A) is important but not the priority in this situation. Calling the physician (B) can be done after the initial assessment on the fetal monitor. Performing glucose (C) is not the priority when the main concern is the well-being of the baby.
A nurse should monitor a client who is postpartum from a forceps delivery for which of the following complications?
- A. Placental abruption.
- B. Seizure.
- C. Idiopathic thrombocytopenia.
- D. Infection.
Correct Answer: D
Rationale: Forceps delivery increases the risk of trauma and infection due to potential tissue damage.
What does a birth plan help the parents accomplish?
- A. Avoidance of an episiotomy
- B. Determining the outcome of the birth
- C. Assuming complete control of the situation
- D. Taking an active part in planning the birth experience
Correct Answer: D
Rationale: The correct answer is D because a birth plan allows parents to actively participate in planning their birth experience by outlining their preferences and wishes. It helps them communicate their desires to healthcare providers and ensures their preferences are considered during labor and delivery. Choice A is incorrect as avoiding an episiotomy is a specific medical procedure, not the primary purpose of a birth plan. Choice B is incorrect as determining the outcome of birth is not within the control of parents. Choice C is incorrect as assuming complete control of the situation may not be realistic or safe during childbirth.