Nokea
A nurse is providing teaching about immunizations to a client who is pregnant. Which of the following statements should the nurse include in the teaching?
- A. The immunization for varicella should be given at least 1 month prior to delivery.
- B. You can receive the rubella immunization during the third trimester of pregnancy.
- C. The hepatitis B immunization should not be obtained until after you finish breastfeeding.
- D. You can receive the immunization for influenza at any time during your pregnancy.
Correct Answer: D
Rationale: The influenza vaccine is safe and recommended during any trimester of pregnancy to protect both the mother and the baby.
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What is the primary intervention for postpartum hemorrhage?
- A. Oxytocin infusion
- B. Methylergonovine injection
- C. Misoprostol administration
- D. Blood transfusion
Correct Answer: A
Rationale: The correct answer is A: Oxytocin infusion. Oxytocin is the first-line medication for postpartum hemorrhage as it helps to contract the uterus, reducing bleeding. It stimulates uterine contractions, which helps to control bleeding by compressing blood vessels. Methylergonovine (B) is contraindicated in hypertensive disorders, Misoprostol (C) is an alternative if oxytocin is not available, and Blood transfusion (D) is a supportive measure after the bleeding is controlled.
A nurse is caring for a 1-month-old infant who has manifestations of severe dehydration and a prescription for parenteral fluid therapy. The guardian asks, 'What are the indications that my baby needs an IV?' Which of the following responses should the nurse make?
- A. Your baby needs an IV because she is not producing tears.
- B. Your baby needs an IV because her heart rate is decreased.
- C. Your baby needs an IV because she is breathing slower than normal.
- D. Your baby needs an IV because her fontanels are bulging.
Correct Answer: A
Rationale: The absence of tears is a sign of severe dehydration, indicating the need for IV fluid therapy to restore hydration.
What is the recommended method of pain relief during labor for a woman who wants to avoid medication?
- A. Acupuncture
- B. Massage
- C. Water immersion
- D. All of the above
Correct Answer: D
Rationale: The correct answer is D: All of the above. Acupuncture, massage, and water immersion are all recommended methods for pain relief during labor for women who want to avoid medication. Acupuncture can help release endorphins, which are natural pain relievers. Massage can reduce muscle tension and promote relaxation. Water immersion, such as in a birthing pool, can provide buoyancy and comfort, easing the intensity of contractions. Each of these methods offers non-pharmacological pain relief options that can be effective during labor. Therefore, choosing all of the above options provides a comprehensive approach to managing pain without medication.
A nurse is providing teaching to the parents of a newborn about the Plastibell circumcision technique. Which of the following information should the nurse include?
- A. The Plastibell will be removed 4 hours after the procedure.
- B. Make sure the newborn’s diaper is snug.
- C. Yellow exudate will form at the surgical site in 24 hours.
- D. Notify the provider if the end of your baby’s penis appears dark red.
Correct Answer: D
Rationale: Correct Answer: D: Notify the provider if the end of your baby’s penis appears dark red.
Rationale: Dark red color at the end of the baby's penis could indicate infection or poor circulation, which are concerning post-circumcision. Promptly notifying the provider can help prevent potential complications.
Summary of other choices:
A: The Plastibell is usually removed after a few days, not 4 hours.
B: Ensuring a snug diaper is not directly related to the Plastibell circumcision technique.
C: Yellow exudate at the surgical site is normal and expected, not a cause for concern.
E, F, G: Not provided in the question, so not applicable.
A nurse is administering a hepatitis B vaccine to a newborn. Which of the following actions should the nurse take?
- A. Administer the injection into the vastus lateralis muscle.
- B. Vigorously massage the site following the injection.
- C. Insert the needle at a 45° angle for injection.
- D. Use a 21-gauge needle for the injection.
Correct Answer: A
Rationale: The correct answer is A, to administer the injection into the vastus lateralis muscle. In newborns, the vastus lateralis muscle is the recommended site for intramuscular injections due to its larger muscle mass and reduced risk of injury to nerves or blood vessels. This site is typically used for vaccines in infants to ensure proper absorption and minimize discomfort. Option B is incorrect as massaging the site can lead to discomfort or tissue damage. Option C is incorrect as inserting the needle at a 45° angle is not necessary for intramuscular injections in newborns. Option D is incorrect as a smaller gauge needle is usually recommended for newborns to reduce pain and tissue trauma.