Nokea
A postpartum client calls the pediatric clinic to report that her 4-day old female newborn has a spot of blood on her diaper. Which of the following statements made by the nurse is most appropriate?
- A. Your newborn may have a urinary infection, continue to breastfeed frequently
- B. Your newborn has jaundice so it may need phototherapy
- C. This is a normal finding due to withdrawal of maternal hormones
- D. Your baby has an immature immune system, continue to breastfeed frequently
Correct Answer: C
Rationale: The correct answer is C because the spot of blood on the diaper of a 4-day old female newborn is a normal finding due to the withdrawal of maternal hormones. During pregnancy, the baby is exposed to maternal hormones, and after birth, the sudden decrease in these hormones can cause a temporary withdrawal bleeding. This is known as pseudomenstruation and is common in newborn girls. It is important for the nurse to reassure the mother that this is a normal and harmless occurrence.
Choice A is incorrect because urinary infection is not typically the cause of blood on the diaper in a newborn. Choice B is incorrect because jaundice does not typically present with blood in the diaper. Choice D is incorrect because while breastfeeding is important for the baby's immune system, it is not directly related to the presence of blood on the diaper in this case.
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The nurse is preparing a client for cesarean delivery. What is the priority nursing action before surgery?
- A. Obtain baseline vital signs.
- B. Insert an indwelling urinary catheter.
- C. Administer prophylactic antibiotics.
- D. Verify signed informed consent.
Correct Answer: D
Rationale: The correct answer is D, verifying signed informed consent. This is the priority because it ensures the client's understanding and agreement to the procedure, respecting their autonomy. Obtaining baseline vital signs (A) is important but not the priority before surgery. Inserting a urinary catheter (B) may be needed but is not the priority over informed consent. Administering antibiotics (C) is important for preventing infection but should not take precedence over confirming the client's informed consent.
Many teens wait until the second or even third trimester to seek prenatal care. The nurse should understand that the reasons behind this delay include which of the following? (Select all that apply.)
- A. Continuing to deny the pregnancy
- B. Uncertainty about where to go for care
- C. Lack of realization that they are pregnant
- D. A desire to gain control over their situation
Correct Answer: A
Rationale: The correct answer is A: Continuing to deny the pregnancy. This is because some teens may struggle to come to terms with their pregnancy and deny it, leading to delays in seeking prenatal care. The other choices are incorrect. B: Uncertainty about where to go for care is not a common reason for delaying prenatal care as resources and information are usually available. C: Lack of realization that they are pregnant is unlikely as most teens eventually become aware of their pregnancy. D: A desire to gain control over their situation does not usually lead to delaying prenatal care as seeking care is a proactive step towards gaining control.
The nurse enters the person's room for the first time. What can the nurse do to show cultural sensitivity?
- A. Come in and sit on the bed with the person.
- B. Address the person by their first name.
- C. Make and hold eye contact.
- D. Document their preferred language in their chart.
Correct Answer: D
Rationale: The correct answer is D because documenting the person's preferred language in their chart shows cultural sensitivity by ensuring effective communication. This step acknowledges and respects the person's cultural background and language preferences, facilitating better understanding and care provision.
Choices A, B, and C are incorrect:
A: Sitting on the bed may invade personal space and not be culturally appropriate.
B: Addressing the person by their first name may not be respectful in some cultures.
C: Making and holding eye contact may be considered rude or inappropriate in certain cultures.
What is a statement that best describes reproductive health?
- A. Reproductive health focuses solely on the ability to reproduce and have children.
- B. Reproductive health encompasses physical well-being but does not include mental and social aspects.
- C. Reproductive health involves complete physical, mental, and social well-being related to the reproductive system.
- D. Reproductive health is limited to making informed decisions about contraception methods.
Correct Answer: C
Rationale: The correct answer is C because reproductive health is not just about the ability to reproduce but also includes mental and social well-being. This choice aligns with the World Health Organization's definition of reproductive health, which emphasizes holistic well-being. Choice A is incorrect as it oversimplifies reproductive health. Choice B is incorrect because reproductive health should address all aspects of well-being. Choice D is incorrect as reproductive health goes beyond just contraception to encompass a broader scope of health and well-being.
The nurse is discussing danger signs during preg- tion procedure. Which statement is appropriate for nancy with a pregnant woman in her first trimester. the nurse to make? Which of the following signs and symptoms would
- A. A catheter is inserted through the cervix into the be appropriate at this time? Select all that apply.
- B. Severe headache and visual changes
- C. Persistent vomiting and nausea
- D. Sperm or ovarian tissue will be frozen for
Correct Answer: B
Rationale: The correct answer is B. Severe headache and visual changes are potential danger signs during the first trimester of pregnancy, indicating conditions like preeclampsia. This is crucial to monitor as it can lead to serious complications for both the mother and the baby.
Choice A is incorrect because inserting a catheter through the cervix is not a relevant danger sign during the first trimester. Choice C, persistent vomiting and nausea, is commonly experienced in the first trimester as morning sickness and is not typically a sign of immediate danger. Choice D, freezing sperm or ovarian tissue, is unrelated to discussing danger signs during pregnancy and does not indicate any potential issues during the first trimester.