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A nurse is teaching the parent of a newborn about car seat safety. Which of the following statements should the nurse make?
- A. You should keep the car seat rear-facing until your baby is at least 2 years old.
- B. Position the retainer clip over the upper part of your baby's abdomen.
- C. You should place your baby in the car seat at a 90-degree angle.
- D. Place the shoulder harness straps in the slots an inch above your baby's shoulders.
Correct Answer: A
Rationale: Rear-facing car seats support a baby's head and spine during sudden stops or collisions. Experts recommend maintaining this position until 2 years to reduce injury risk.
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A nurse is teaching a client about using an intrauterine device (IUD) for contraception. Which of the following client statements indicates an understanding of the teaching?
- A. I will need to have the IUD replaced each year.
- B. I will need to apply a spermicide prior to intercourse.
- C. I should expect my periods to stop while I have the IUD.
- D. I should check for the string each month after menstruation.
Correct Answer: D
Rationale: Checking for the string ensures proper IUD positioning and functionality. This monthly practice helps detect dislodgement or expulsion, which can compromise contraceptive effectiveness.
A nurse is caring for a client who is in labor and has an epidural for pain control. Which of the following clinical manifestations is an adverse effect of epidural anesthesia?
- A. Polyuria.
- B. Hypertension.
- C. Pruritus.
- D. Dry mouth.
Correct Answer: C
Rationale: Pruritus is a frequent side effect of epidural anesthesia, particularly when using opioids like fentanyl, due to histamine release or opioid receptors activation in the spinal cord.
For each body system below, specify the potential complications that can occur. Match the body system with the potential complications.
- A. Hypotonia
- B. Seizures
- C. Hearing loss
Correct Answer: B
Rationale: Neurologic: Seizures (B) - due to potential neurological dysfunction. Musculoskeletal: Hypotonia (A) - indicating muscle weakness. Head, ears, eyes, nose, and throat: Hearing loss (C) - from auditory nerve or structural damage.
A client reports an intermittent dark brown vaginal discharge for the past three days. What should the nurse do?
- A. The nurse should assess the client for signs of molar pregnancy.
- B. The nurse should evaluate the risk for hypovolemic shock due to blood loss.
- C. The nurse should ensure appropriate laboratory testing for the diagnosis of choriocarcinoma.
- D. The nurse should prioritize preparing the client for suction and curettage.
Correct Answer: A
Rationale: Molar pregnancy often manifests as intermittent dark brown vaginal discharge due to trophoblastic tissue expulsion. It warrants assessment as it correlates with hCG elevation and abnormal placental development.
A nurse is caring for a client who is in labor and has a diagnosis of group B streptococcus B-hemolytic infection. Which of the following medications should the nurse plan to administer?
- A. Ampicillin.
- B. Azithromycin.
- C. Ceftriaxone.
- D. Acyclovir.
Correct Answer: A
Rationale: Ampicillin is a first-line antibiotic effective against group B streptococcus B-hemolytic bacteria, preventing neonatal infection during labor. It targets the bacterial cell wall synthesis and is safe in pregnancy.