Nokea
A young woman who underwent a liver transplant one year ago tells the clinic nurse that she would like to start a family. How should the nurse intervene?
- A. Provide information about the high-risk nature of her pregnancy.
- B. Gently remind the client that anti-rejection drugs can cause sterility.
- C. Explain the benefits of waiting for a five-year post-transplant period.
- D. Determine if the client is considering options for adopting a child.
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
You may also like to solve these questions
A male infant with a 2-day history of fever and diarrhea is brought to the clinic by his mother, who tells the nurse that the child refuses to drink anything. The nurse determines that the child has a weak cry with no tears. Which intervention is most important to implement?
- A. Provide a bottle of electrolyte solution.
- B. Infuse normal saline intravenously.
- C. Administer an antipyretic rectally.
- D. Apply an external cooling blanket.
Correct Answer: B
Rationale: Infusing normal saline intravenously is crucial to treat dehydration caused by fever and diarrhea. In this scenario, the infant's weak cry with no tears indicates severe dehydration, necessitating rapid fluid replacement via intravenous normal saline to restore fluid balance and prevent complications.
After two miscarriages, a client is instructed to increase her daily intake of foods that include folic acid. The client does not like green leafy vegetables and states she is allergic to soy. Which food should the nurse suggest that the client eat to obtain folic acid?
- A. Strawberries.
- B. Yogurt.
- C. Collard greens.
- D. Whole milk.
Correct Answer: C
Rationale: Collard greens are a good source of folic acid, which is important for preventing neural tube defects, especially in clients with a history of miscarriages. Since the client does not like green leafy vegetables, collard greens could be suggested as an alternative source of folic acid. Yogurt and whole milk do not contain significant amounts of folic acid, and while strawberries are a healthy choice, they are not a high source of folic acid compared to collard greens.
During a newborn assessment, which symptom would indicate respiratory distress if present in a newborn?
- A. Flaring of the nares.
- B. Shallow and irregular respirations.
- C. Respiratory rate of 50 breaths per minute.
- D. Abdominal breathing with synchronous chest movement.
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The nurse is assessing a newborn who was precipitously delivered at 38 weeks' gestation. The newborn is tremulous, tachycardic, and hypertensive. Which assessment action is most important for the nurse to take?
- A. Perform a gestational age assessment.
- B. Obtain a drug screen for cocaine.
- C. Determine reactivity of neonatal reflexes.
- D. Weigh and measure the newborn.
Correct Answer: B
Rationale: The correct answer is to obtain a drug screen for cocaine. Tremulousness, tachycardia, and hypertension in a newborn can be signs of neonatal abstinence syndrome, often caused by maternal drug use, such as cocaine. Identifying maternal drug use is crucial for appropriate management and treatment of the newborn.
During the newborn admission assessment, the nurse palpates the newborn's scrotum and does not feel the testicles. Which assessment technique should the nurse perform next to verify the absence of testes?
- A. Observe the urethral opening on the surface of the penis when the newborn voids.
- B. Perform transillumination of the scrotal sac to visualize shadows of the testes.
- C. Use a fingertip to palpate the inguinal canal for a retractile or undescended testis.
- D. Measure the size of the scrotal sac for length and width.
Correct Answer: C
Rationale: If the testes are not palpated in the scrotum, the next step is to check the inguinal canal for a retractile or undescended testis. This technique allows the nurse to determine if the testes are located within the inguinal canal rather than the scrotum. It is essential to assess for the presence of testes in the inguinal canal to ensure proper diagnosis and management of any potential issues related to testicular positioning.