Nokea
A preterm neonate develops physiologic jaundice and phototherapy is ordered. The nurse understands that this therapy:
- A. Activates the liver to dispose the bilirubin
- B. Breaks down the unconjugated bilirubin in the skin to conjugated form permitting excretion
- C. Activates Vit. K to facilitate excretion of the bilirubin
- D. Dissolves the bilirubin and allows it to be excreted from the skin
Correct Answer: B
Rationale: The correct answer is B because phototherapy works by breaking down unconjugated bilirubin in the skin to a water-soluble form, allowing it to be excreted from the body. This process does not activate the liver (choice A), nor does it activate Vitamin K (choice C) or dissolve the bilirubin for excretion from the skin (choice D). Phototherapy specifically targets the unconjugated bilirubin in the skin, converting it to a form that can be eliminated through the urine and stool.
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The nurse is monitoring a client in labor and suspects hypertonic uterine contractions. What is the priority nursing action?
- A. Provide pain relief measures.
- B. Prepare the client for an amniotomy.
- C. Promote ambulation every 30 minutes.
- D. Monitor the oxytocin infusion closely.
Correct Answer: A
Rationale: The correct answer is A: Provide pain relief measures. In hypertonic uterine contractions, the uterus contracts too frequently and intensely, leading to increased pain and potential fetal distress. Providing pain relief helps alleviate discomfort for the client and may reduce the risk of fetal distress. Other choices are incorrect because: B) Amniotomy may not be necessary and could potentially worsen the situation. C) Ambulation may not be safe or effective during hypertonic contractions. D) Monitoring the oxytocin infusion closely is important but not the priority in managing hypertonic contractions.
The nurse is educating a client about folic acid during pregnancy. What food should the nurse recommend?
- A. Citrus fruits.
- B. Leafy green vegetables.
- C. Dairy products.
- D. Lean meats.
Correct Answer: B
Rationale: The correct answer is B: Leafy green vegetables. Folic acid is essential during pregnancy for proper fetal development. Leafy green vegetables like spinach, kale, and broccoli are rich sources of folic acid. Citrus fruits (Choice A) contain vitamin C but not as much folic acid as leafy greens. Dairy products (Choice C) provide calcium but are not significant sources of folic acid. Lean meats (Choice D) are good sources of protein but do not contain as much folic acid as leafy green vegetables. Therefore, recommending leafy green vegetables ensures the client gets an adequate intake of folic acid during pregnancy.
A nurse in a prenatal clinic is teaching a client who has a new prescription for dinoprostone gel. Which of the following statements should the nurse include in the teaching?
- A. "This medication promotes softening of the cervix."
- B. "This medication is used to treat preeclampsia."
- C. "It causes relaxation of the uterine muscles."
- D. "It is used to treat genital herpes simplex virus."
Correct Answer: A
Rationale: The correct answer is A: "This medication promotes softening of the cervix." Dinoprostone gel is a prostaglandin used to ripen the cervix in preparation for labor induction. This explanation is crucial for the client to understand the purpose of the medication. Option B is incorrect because dinoprostone is not used to treat preeclampsia. Option C is incorrect as dinoprostone causes uterine contractions rather than relaxation. Option D is incorrect as dinoprostone is not used to treat genital herpes simplex virus.
What is the best position for a laboring mother with a suspected occiput posterior position?
- A. Encourage side-lying position
- B. Place the mother in lithotomy position
- C. Encourage ambulation to facilitate descent
- D. Use a peanut ball to widen the pelvis
Correct Answer: D
Rationale: The correct answer is D. Using a peanut ball widens the pelvis, which can help rotate the baby into an optimal position for birth. This position can aid in reducing the likelihood of prolonged labor and the need for interventions. Encouraging side-lying position (A) may not provide the necessary pelvic widening. Placing the mother in lithotomy position (B) can impede the baby's descent. Encouraging ambulation (C) may not specifically address the occiput posterior position and may not provide enough pelvic opening.
Developing a plan to achieve patient outcomes is included in which step of the CJMM?
- A. prioritizing hypotheses
- B. generating solutions
- C. taking action
- D. evaluating outcomes
Correct Answer: B
Rationale: The correct answer is B: generating solutions. In the CJMM (Clinical Judgment Model in Nursing), developing a plan to achieve patient outcomes falls under the step of generating solutions. This step involves identifying and implementing interventions to address the patient's needs and achieve the desired outcomes. Prioritizing hypotheses (A) is about identifying potential issues, not developing a plan. Taking action (C) is about implementing the plan, not developing it. Evaluating outcomes (D) is the final step where the effectiveness of the plan is assessed, not where the plan is developed. Therefore, B is the correct choice as it specifically focuses on the process of creating a plan to achieve patient outcomes within the CJMM.