Nokea
A nurse is teaching a prenatal class about immunizations that newborns receive following birth. Which of the following immunizations should the nurse include in the teaching?
- A. Hepatitis B
- B. Rotavirus
- C. Pneumococcal
- D. Varicella
Correct Answer: A
Rationale: The correct answer is A: Hepatitis B. Newborns typically receive the Hepatitis B vaccine shortly after birth to provide protection against the virus. This is important because newborns are at risk of contracting Hepatitis B from infected mothers during childbirth. The vaccine helps prevent chronic liver infections and liver cancer later in life.
Why other choices are incorrect:
B: Rotavirus - Rotavirus vaccine is typically given to infants starting at 2 months of age, not immediately after birth.
C: Pneumococcal - Pneumococcal vaccines are usually given later in infancy, not right after birth.
D: Varicella - Varicella vaccine is typically given around 12-15 months of age, not immediately after birth.
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The nurse is assessing a client with hyperemesis gravidarum. What lab finding is most concerning?
- A. Elevated hematocrit.
- B. Decreased potassium.
- C. Increased white blood cell count.
- D. Low fasting blood glucose.
Correct Answer: B
Rationale: The correct answer is B: Decreased potassium. In hyperemesis gravidarum, excessive vomiting can lead to electrolyte imbalances, particularly hypokalemia. Potassium plays a crucial role in nerve and muscle function, so a low potassium level can result in serious complications such as cardiac arrhythmias. Elevated hematocrit (A) may indicate dehydration, but it is not as immediately concerning as potassium imbalance. Increased white blood cell count (C) may suggest infection but is not directly related to hyperemesis gravidarum. Low fasting blood glucose (D) can occur due to inadequate nutrient intake but is not the most concerning finding in this case.
During the assessment of a newborn, it is most important for the nurse to report a:
- A. Temperature of 97.7 degrees Fahrenheit
- B. Pale pink, rust-colored stain in the diaper
- C. Heart rate that drops to 120 beats/min
- D. Breathing pattern that is diaphragmatic with sternal retractions
Correct Answer: D
Rationale: The correct answer is D because a breathing pattern that is diaphragmatic with sternal retractions indicates respiratory distress in a newborn, which is a critical condition requiring immediate attention. Staying logical, let's assess the other choices:
A: Temperature of 97.7 degrees Fahrenheit is within the normal range for a newborn and does not indicate an urgent issue.
B: A pale pink, rust-colored stain in the diaper could be due to various factors such as diet and is not an immediate concern.
C: A heart rate dropping to 120 beats/min in a newborn is generally within the normal range and does not signify a critical issue.
The nurse is assessing a client with a suspected diagnosis of abruptio placentae. Which finding is most indicative of this condition?
- A. Soft abdomen.
- B. Uterine tenderness and rigidity.
- C. Bright red, painless vaginal bleeding.
- D. Decreased fetal movements.
Correct Answer: B
Rationale: The correct answer is B: Uterine tenderness and rigidity. This finding is most indicative of abruptio placentae, which is the premature separation of the placenta from the uterine wall. Uterine tenderness and rigidity are classic signs due to the internal bleeding and blood accumulating between the placenta and uterine wall. This results in a tense and tender uterus.
A: Soft abdomen is incorrect as abruptio placentae typically presents with a firm, board-like abdomen due to uterine rigidity.
C: Bright red, painless vaginal bleeding is incorrect as abruptio placentae typically presents with dark red, painful vaginal bleeding.
D: Decreased fetal movements are incorrect as fetal distress can occur with abruptio placentae, but uterine tenderness and rigidity are more specific indicators of this condition.
Which herbs would you counsel a lactating client to use to stimulate blood flow to the breast glands, stimulate milk production, and enrich milk flow?
- A. Milk thistle
- B. Cabbage juice
- C. Lanolin
- D. Aloe vera
Correct Answer: B
Rationale: The correct answer is B: Cabbage juice. Cabbage juice contains phytoestrogens that help stimulate blood flow to the breast glands and promote milk production. It is used traditionally to increase milk supply in lactating women. Milk thistle (A) is more commonly used for liver health and not specifically for lactation. Lanolin (C) is a topical ointment for sore nipples, not for milk production. Aloe vera (D) is not recommended for internal use during lactation due to potential laxative effects. In summary, cabbage juice is the best choice as it directly supports milk production and flow in lactating clients.
A nurse is reviewing signs of effective breathing with a client who is 5 days postpartum. Which of the following information should the nurse include in the teaching?
- A. "You should feel a tugging sensation when the baby is sucking.
- B. You should expect your baby to have two to three wet diapers in 24hour period
- C. "Your baby's urine should appear dark and concentrated".
- D. "Your breast should stay firm after the baby breastfeeds".
Correct Answer: B
Rationale: Rationale: Choice B is correct because a newborn should have at least 6-8 wet diapers in a 24-hour period, indicating adequate hydration and effective breastfeeding. This frequency of wet diapers is a sign of adequate milk intake and hydration for the baby, which is crucial for their growth and development. Choices A, C, and D are incorrect because feeling a tugging sensation, dark and concentrated urine, and firm breasts are not indicators of effective breathing or breastfeeding in a newborn.