Nokea
A nurse receives report about assigned clients at the start of the shift. Which of the following clients should the nurse plan to see first?
- A. A client who experienced a cesarean birth 4 hr ago and reports pain
- B. A client who has preeclampsia with a BP of 138/90 mm Hg
- C. A client who experienced a vaginal birth 24 hr ago and reports no bleeding
- D. A client who is scheduled for discharge following a laparoscopic tubal ligation Which of the following findings indicates that it is safe for the nurse to continue the infusion? .
Correct Answer: A
Rationale: The client who experienced a cesarean birth 4 hours ago and is reporting pain should be seen first by the nurse. Pain assessment and management are crucial following a cesarean birth to ensure the client's comfort and well-being. Uncontrolled pain can lead to complications and affect the client's recovery process. Addressing the client's pain promptly is a priority to promote their comfort and facilitate their recovery.
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Which congenital defects in a newborn are associated with long-term parenting problems? (Select all that apply.)
- A. Polydactyl
- B. Cleft lip and palate
- C. Ventral septal defect
- D. Ambiguous genitalia
Correct Answer: B
Rationale: 1. Cleft lip and palate: Parents of a newborn with a cleft lip and palate may face challenges related to feeding difficulties, speech development issues, and concerns about their child's appearance. These issues can require additional medical interventions and support, leading to long-term parenting stress and psychological strain.
Why should a woman refrain from douching while menstruating?
- A. Fibroids.
- B. Endometritis.
- C. Cervical cancer.
- D. Polyps.
Correct Answer: B
Rationale: Douching disrupts vaginal flora and increases infection risk.
The nurse assess that a newborn is in respiratory distress when the infant exhibits:
- A. Apnea, grunting, wheezing, and crackles
- B. Wheezing, cyanosis, hiccups, and crackles
- C. Cyanosis, retraction, wheezing, and hiccups
- D. Tachypnea, retraction, grunting, and cyanosis
Correct Answer: D
Rationale: These are classic signs of respiratory distress.
Most newborns receive a prophylactic injection of vitamin K soon after birth. Which site is appropriate for the newborn?
- A. Gluteal muscles
- B. Rectus femoris muscle
- C. Deltoid muscle
- D. Vastus lateralis muscle
Correct Answer: D
Rationale: Vastus lateralis muscle is the recommended site due to its size and safety.
The nurse is educating a client with gestational diabetes about blood sugar monitoring. What statement indicates understanding?
- A. I will check my blood sugar once a week.
- B. I should avoid all carbohydrates.
- C. I will monitor my blood sugar four times a day as prescribed.
- D. I can skip insulin on days I feel well.
Correct Answer: C
Rationale: Frequent monitoring of blood sugar is essential for managing gestational diabetes effectively.