Nokea
A nurse sees an overweight woman looking at the babies through the nursery window. The woman asks the nurse when the babies go to their mothers for feedings and about the location of the nearest stairwell. Which of the following replies by the nurse is most appropriate at this time?
- A. The babies go to their mothers whenever they seem hungry.'
- B. Please let me escort you to the mother’s room you are here to visit.'
- C. The babies are in the mothers’ rooms for the majority of the day.'
- D. Most of our visitors prefer to use the elevator to return to the lobby.'
Correct Answer: B
Rationale: Escorting the visitor ensures she reaches the correct destination and maintains security in the nursery area.
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The nurse is measuring the fundal height of a patient who is at 34 weeks of gestation. What fundal height measurement is expected for a patient who is at 34 weeks of gestation?
- A. 31 cm
- B. 33 cm
- C. 37 cm
- D. 38 cm
Correct Answer: C
Rationale: The correct answer is C (37 cm) because at 34 weeks of gestation, the fundal height measurement should be approximately equal to the number of weeks of gestation in centimeters. This is known as the "fundal height equals gestational age" rule. Therefore, at 34 weeks, the expected fundal height measurement should be around 34 cm. Option C (37 cm) is the closest to this expected measurement. Options A, B, and D are incorrect as they do not align with the fundal height expected at 34 weeks of gestation. Option A (31 cm) is too low, Option B (33 cm) is also lower than expected, and Option D (38 cm) is too high for 34 weeks of gestation.
A nurse provides immunization to children and adults through the public health department. Which type of health care is the nurse providing?
- A. Primary care
- B. Preventive care
- C. Restorative care
- D. Continuing care
Correct Answer: B
Rationale: Preventive care includes immunizations, screenings, counseling, crisis prevention, and community safety legislation.
A breastfeeding client, 6 days postdelivery, calls the postpartum unit stating, “I think I am engorged. My breasts are very hard and hot and they really hurt.” Which of the following questions should the nurse ask at this time?
- A. “Have you taken a warm shower this morning?”
- B. “Do you have an electric breast pump?”
- C. “How much did you have to drink yesterday?”
- D. “When was the last time you fed the baby?”
Correct Answer: D
Rationale: Asking when the client last fed the baby helps determine if engorgement is due to infrequent feeding, which is a common cause of breast engorgement.
Which of the following features would the nurse expect to be absent in an 8-week-gestation embryo?
- A. Four-chambered heart.
- B. Fingers and toes.
- C. Fully formed genitalia.
- D. Facial features.
Correct Answer: C
Rationale: At 8 weeks, the embryo’s genitalia are not fully formed, though other features like the heart and facial structures are developing.
The nurse is working with a pregnant woman who states that she is a vegan. Which of the following actions by the nurse is appropriate?
- A. Advise the mother that she must eat some animal protein during her pregnancy.
- B. Refer the woman to a nutritionist for diet counseling.
- C. Remind the mother that cashews and coconut are excellent sources of calcium.
- D. Congratulate the woman on agreeing to eat eggs and milk.
Correct Answer: B
Rationale: A nutritionist can help ensure the vegan mother receives adequate nutrients, such as B12, iron, and protein, during pregnancy.