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After delivering a healthy newborn 1 hour ago, a nurse notes a woman's radial pulse rate is 55 beats/min. What action should the nurse take based on this finding?
- A. Reporting the finding to the healthcare provider immediately
- B. Helping the woman stay in bed and rest
- C. Documenting the finding
- D. Performing active and passive range-of-motion exercises
Correct Answer: C
Rationale: After delivery, bradycardia (pulse rate 50-70 beats/min) may occur, reflecting the large amount of blood returning to the central circulation after delivery of the placenta. The increase in central circulation results in increased stroke volume, allowing a slower heart rate to provide adequate maternal circulation. A pulse rate of 55 beats/min falls within the normal range post-delivery, so there is no need to notify the healthcare provider immediately. It is important for the client to remain on bed rest in the immediate postpartum period to prevent complications. While range-of-motion exercises are beneficial for a client on bed rest, it is not the priority based on the data provided. Therefore, the most appropriate nursing action is to document the finding for accurate record-keeping and monitoring of the client's condition.
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Which of the following vaccines is not part of the regular schedule of immunizations for children?
- A. DTaP
- B. MMR
- C. Hib
- D. hepatitis A
Correct Answer: D
Rationale: The correct answer is hepatitis A. DTaP, MMR, and Hib are all part of the regular schedule of immunizations for children to protect them against diseases like diphtheria, tetanus, pertussis, measles, mumps, rubella, and Haemophilus influenzae type b. Hepatitis A vaccine is not included in the routine childhood immunization schedule but may be recommended in certain situations or regions where the disease is more prevalent. Hepatitis A is generally considered an optional vaccine for children but can be administered based on specific risk factors or regional guidelines.
A woman in labor whose cervix is not completely dilated is pushing strenuously during contractions. Which method of breathing should the nurse encourage the woman to perform to help her overcome the urge to push?
- A. Holding her breath and using the Valsalva maneuver
- B. Blowing repeatedly in short puffs
- C. Cleansing breaths
- D. Deep inspiration and expiration at the beginning and end, respectively, of each contraction
Correct Answer: B
Rationale: If a woman pushes strenuously before the cervix is completely dilated, she risks injury to the cervix and the fetal head. Blowing prevents closure of the glottis and breath-holding, helping overcome the urge to push strenuously. The woman would be encouraged to blow repeatedly, using short puffs, when the urge to push is strong. This breathing technique allows for controlled exhalation and helps prevent unnecessary pushing. Cleansing breaths (deep inspiration and expiration at the beginning and end of each contraction) are encouraged during the first stage of labor to provide oxygenation and reduce myometrial hypoxia and to promote relaxation. Holding her breath and using the Valsalva maneuver (choice A) is not recommended as it can increase intra-abdominal pressure and decrease venous return, potentially compromising fetal oxygenation. Deep inspiration and expiration at the beginning and end of each contraction (choice D) are more suitable for relaxation and oxygenation purposes rather than managing the urge to push.
Before administering the hepatitis B vaccine to a newborn infant, what should the nurse do?
- A. Request parental consent to administer the vaccine.
- B. Check the infant for jaundice.
- C. Check the infant's temperature.
- D. Obtain parental consent to administer the vaccine.
Correct Answer: D
Rationale: Before administering the hepatitis B vaccine to a newborn infant, the nurse must obtain parental consent. Hepatitis B vaccine is typically given at birth, 1 month, and 6 months of age. Checking the infant for jaundice, checking the temperature, and requesting a hepatitis blood screen are unnecessary in this context. Parental consent is crucial for any medical intervention involving minors.
A pregnant client is being educated by a nurse on nutrition and foods rich in folic acid. Which food item does the nurse inform the client contains the highest amount of folic acid?
- A. Pinto beans
- B. Lettuce
- C. Oranges
- D. Broccoli
Correct Answer: A
Rationale: Pinto beans contain the highest amount of folic acid among the options provided, with 294 mcg per 1-cup serving. Oranges contain 44 mcg per 1-cup serving, lettuce contains 60 mcg per 1-cup serving, and broccoli contains 78 mcg per 1-cup serving. Therefore, pinto beans are the best choice for increasing folic acid intake during pregnancy. Choosing oranges, lettuce, or broccoli would not provide as much folic acid compared to pinto beans, making them less optimal choices for meeting folic acid requirements during pregnancy.
When a client who is having trouble conceiving says to the nurse, 'I have started taking ginseng,' the best response by the nurse is:
- A. "There is some evidence that ginseng may enhance in vitro sperm motility."?
- B. "Some studies show that ginseng enhances in vitro sperm motility."?
- C. "Ginseng is not proven to be effective for infertility; have you considered other options?"?
- D. "It's probably not going to hurt you, but it's also probably not going to help. Let's look at some other alternatives."?
Correct Answer: B
Rationale: Some studies have shown that ginseng enhances in vitro sperm motility, making Choice B the correct response. It directly addresses the client's comments about taking ginseng and provides valuable information regarding its potential effect on sperm motility. Alternative therapies are often sought by couples struggling with infertility, and acknowledging the potential benefits of ginseng can empower the client. Choice A is incorrect as it slightly misrepresents the evidence by overgeneralizing its effectiveness. Choice C dismisses ginseng without acknowledging its potential benefits, potentially closing off a fruitful discussion with the client. Choice D, while neutral, misses the opportunity to validate the client's choice and explore further options collaboratively. It is crucial for nurses to respect clients' choices, provide accurate information, and guide them effectively in exploring different alternatives.