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A nurse is reinforcing teaching with the parent of a child with a urinary tract infection.
- A. "I will bring my child to the bathroom before we leave for extended trips."'
- B. "I need to switch my child from cotton underwear to nylon underwear."'
- C. "I should teach my child to wipe from back to front after urinating."'
- D. "I will have my child soak in a bubble bath once or twice a week."'
Correct Answer: A
Rationale: Correct Answer: A. "I will bring my child to the bathroom before we leave for extended trips."
Rationale: Bringing the child to the bathroom before extended trips helps prevent urinary stasis and decreases the risk of urinary tract infections by promoting regular voiding. This practice ensures that the bladder is emptied regularly, reducing the chances of bacterial growth. It is important to encourage frequent urination to flush out bacteria and prevent infection.
Summary of other choices:
B: Switching from cotton to nylon underwear can increase moisture retention and promote bacterial growth, leading to an increased risk of urinary tract infections.
C: Teaching a child to wipe from back to front can introduce bacteria from the anal area to the urethra, increasing the risk of urinary tract infections.
D: Soaking in a bubble bath can irritate the urethra and disrupt the natural balance of bacteria in the genital area, potentially leading to urinary tract infections.
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A client reports awaking from sleep by contractions that are occurring every five minutes and lasting 30-40 seconds. Which of the following questions should the nurse ask to assess for true labor versus false labor?
- A. When did your contractions begin?
- B. Have you noticed any bloody show or fluid coming from your vagina?
- C. What happens to your contractions when you move about?
- D. Have you felt fetal movement over the last 24 hours?
Correct Answer: B
Rationale: The correct answer is B. The presence of bloody show or fluid coming from the vagina can indicate ruptured membranes, which is a sign of true labor. This is important in determining whether the client is in active labor. Asking about the presence of bloody show or fluid helps differentiate between true and false labor.
Choice A is less relevant as the timing of contractions alone does not distinguish between true and false labor. Choice C is related to assessing the effectiveness of contractions, not differentiating between true and false labor. Choice D is important for assessing fetal well-being but does not help in distinguishing between true and false labor.
A nurse is caring for a toddler who is in an oxygen tent. Which of the following actions should the nurse take in order to promote comfort while maintaining the child's safety?
- A. Give the child a stuffed animal and car with rubber wheels to play with.
- B. "Give the child a stuffed animal and car with rubber wheels to play with."'
- C. "Change the bedding and the child's clothing frequently or as often as needed."'
- D. "Tuck the bottom of the tent under the mattress on three sides,leaving one side open so the child can look out."'
Correct Answer: C
Rationale: The correct answer is C. Changing the bedding and the child's clothing frequently promotes comfort by ensuring cleanliness and preventing skin irritation. This action also maintains the child's safety by reducing the risk of infections and skin breakdown. Giving a stuffed animal and a car with rubber wheels (Choice A) may pose a choking hazard. Tucking the bottom of the tent under the mattress on three sides (Choice D) may restrict airflow and increase the risk of suffocation.
The nursery nurse reviews a newborn's birth history and notes that the Apgar scores were 5 at one minute after birth, and 7 at five minutes after birth. How should the nurse interpret these scores? The infant:
- A. Needed brief oral and nasal suctioning.
- B. Required endotracheal intubation and bagging with a hand-held resuscitator.
- C. Was stillborn and required CPR.
- D. Required physical stimulation and supplemental oxygen.
Correct Answer: D
Rationale: The correct answer is D: Required physical stimulation and supplemental oxygen. The Apgar score assesses a newborn's overall condition at birth based on five criteria: heart rate, respiratory effort, muscle tone, reflex irritability, and color. A score of 5 at one minute indicates the infant needed assistance, such as stimulation to breathe and oxygen support. The score of 7 at five minutes shows improvement but still requires some intervention. Choices A, B, and C are incorrect because they suggest more aggressive interventions that are not indicated based on the Apgar scores provided, as the infant's condition was not critical enough to warrant those actions.
A nurse is reinforcing teaching to a group of parents about preventing accidental poisoning in preschoolers.
- A. "Have syrup of ipecac available in the home."'
- B. "Explain to preschool children that plants can be eaten only after they are cooked."'
- C. "Keep labels on containers of toxic substances and never remove them."'
- D. "Place medications in a cabinet above the sink."'
Correct Answer: C
Rationale: The correct answer is C. Keeping labels on containers of toxic substances is crucial as it provides important information about the contents and hazards. Removing labels can lead to confusion and accidental ingestion. Syrup of ipecac (choice A) is no longer recommended for poisoning treatment. Teaching children to eat cooked plants (choice B) does not address the issue of accidental poisoning. Placing medications above the sink (choice D) may still be accessible to preschoolers.
The nurse notices a variable deceleration on a fetal monitor strip. Which nursing action is appropriate?
- A. Instruct the mother to breathe slowly because this is a sign of hyperventilation
- B. Decrease the amount of Pitocin because this is a sign of hypertonic uterine contractions
- C. Turn the woman onto her left side to relieve pressure on the umbilical cord
- D. Reduce the oral and IV fluids to decrease circulatory overload
Correct Answer: C
Rationale: The correct answer is C: Turn the woman onto her left side to relieve pressure on the umbilical cord. Variable decelerations are associated with umbilical cord compression. Turning the woman onto her left side can help relieve pressure on the cord, improving fetal oxygenation. This position change is a non-invasive, quick intervention that can potentially resolve the variable decelerations.
Choice A is incorrect because variable decelerations are not typically associated with hyperventilation. Choice B is incorrect as decreasing Pitocin may not directly address the underlying cause of the variable decelerations. Choice D is incorrect because reducing fluids may not address the immediate concern of umbilical cord compression.