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A nurse is receiving laboratory results for a term newborn who is 24 hr. old. Which of the following results require intervention by the nurse?
- A. WBC count 10,000/mm3
- B. Platelets 180,000/mm3
- C. Hemoglobin 20g/dL
- D. Glucose 20 mg/dL
Correct Answer: D
Rationale: The correct answer is D because a glucose level of 20 mg/dL in a term newborn is significantly low and requires immediate intervention by the nurse. Low glucose levels can lead to hypoglycemia, which can be harmful to the newborn's brain development and overall health. A WBC count of 10,000/mm3 is within normal range for a newborn. Platelets of 180,000/mm3 and hemoglobin of 20g/dL are also within normal limits for a term newborn and do not require intervention.
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A nurse is providing nutritional guidance to a client who is pregnant and follows a vegan diet. The client asks the nurse which foods she should eat to ensure adequate calcium intake. The nurse should instruct the client that which of the following foods has the highest amount of calcium?
- A. ½ cup cubed avocado
- B. 1 large banana
- C. 1 medium potato
- D. 1 cup cooked broccoli
Correct Answer: D
Rationale: The correct answer is D: 1 cup cooked broccoli. Broccoli is a good source of calcium, with approximately 70 mg per cup. This is higher than the other options provided. Avocado, banana, and potato are not significant sources of calcium compared to broccoli. Broccoli is a suitable choice for a pregnant vegan to ensure adequate calcium intake. It is important for the client to consume a variety of plant-based calcium-rich foods to meet their nutritional needs during pregnancy.
The nurse is preparing a client for cesarean delivery. What is the priority nursing action before surgery?
- A. Obtain baseline vital signs.
- B. Insert an indwelling urinary catheter.
- C. Administer prophylactic antibiotics.
- D. Verify signed informed consent.
Correct Answer: D
Rationale: The correct answer is D, verifying signed informed consent. This is the priority because it ensures the client's understanding and agreement to the procedure, respecting their autonomy. Obtaining baseline vital signs (A) is important but not the priority before surgery. Inserting a urinary catheter (B) may be needed but is not the priority over informed consent. Administering antibiotics (C) is important for preventing infection but should not take precedence over confirming the client's informed consent.
Nutrition is an integral part of the Bradley Method. What important nutrition advice is taught in this method?
- A. Only eat low-fat foods.
- B. Increase protein to 100 g per day.
- C. Do not eat dairy because it causes food allergies.
- D. Eat a low-protein diet.
Correct Answer: B
Rationale: The correct answer is B because the Bradley Method emphasizes the importance of increasing protein intake to support a healthy pregnancy. Protein is essential for fetal development and maternal health. It is recommended to consume around 100g of protein per day during pregnancy. Adequate protein intake helps in the growth of the baby and helps to maintain the health of the mother.
Explanation of why the other choices are incorrect:
A: Only eat low-fat foods - This is incorrect as fat is also important for a healthy pregnancy and should not be eliminated entirely.
C: Do not eat dairy because it causes food allergies - Dairy is a good source of calcium and other essential nutrients during pregnancy, so this advice is not recommended.
D: Eat a low-protein diet - This is incorrect as protein is crucial for the development of the baby and overall health during pregnancy.
A nurse is giving post-op teaching to a person after a surgical abortion. What education should be provided?
- A. Report bleeding that is heavy, soaks more than two pads per hour for 2 hours.
- B. You can resume vaginal coitus the next day.
- C. You do not need to return to the clinic for follow-up.
- D. You should use tampons if your bleeding is heavy.
Correct Answer: A
Rationale: The correct answer is A because heavy bleeding post-surgical abortion can indicate a complication like hemorrhage, so prompt reporting is crucial. Choice B is incorrect as resuming vaginal intercourse too soon can increase the risk of infection. Choice C is incorrect because follow-up care is essential to monitor for complications. Choice D is incorrect as tampons should be avoided to reduce the risk of infection. In summary, choice A is correct as it prioritizes patient safety and early detection of complications.
A nurse is teaching the parents of a newborn how to care for their child's uncircumcised penis. Which of the following instructions should the nurse include?
- A. Retract the foreskin until you feel resistance.
- B. Use a cotton swab to clean under the foreskin.
- C. Apply petroleum jelly to the foreskin.
- D. Wash the penis once per day with soup and water.
Correct Answer: D
Rationale: The correct answer is D because washing the penis once per day with soap and water is the appropriate way to care for an uncircumcised penis. This helps maintain good hygiene and prevents infections. Retracting the foreskin forcefully (Choice A) can cause injury and should not be done until the child is older. Using a cotton swab (Choice B) can leave fibers behind and may cause irritation. Applying petroleum jelly (Choice C) is unnecessary and can increase the risk of infections. Therefore, washing the penis with soap and water daily is the most effective and safe method for caring for an uncircumcised penis.