Nokea
After reviewing the child's immunization record, which scheduled vaccine should the nurse prepare to administer next?
- A. Hib
- B. IPV
- C. MMR
- D. DTaP
Correct Answer: D
Rationale: The correct answer is DTaP. DTaP is administered at 2, 4, and 6 months of age; between 15 and 18 months of age; and between 4 and 6 years of age. Since the child has only received three doses of this vaccine, the next dose of DTaP should be administered. The other options are incorrect because Hib is administered at 2, 4, and 6 months of age and between 12 and 15 months; IPV is administered at 2, 4, and 6 months of age and between 4 and 6 years of age; MMR is administered between 12 and 15 months of age and again between 4 and 6 years of age.
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A preschooler has successfully completed the test item 'counts 5 blocks' on the Denver II test. This pass is evidence of which of the following developmental concepts?
- A. centration
- B. causality
- C. nonreversibility
- D. conservation
Correct Answer: D
Rationale: The ability of a preschooler to move five blocks to a piece of paper and state there are five blocks on the paper is evidence that the preschooler has the ability of conservation. This concept refers to the fact that the quantity of something doesn't change just because the shape, contour, and so on has changed. Five blocks are still five blocks, whether they are lying beside the paper, stacked on the paper, or moved to the paper. Centration is the ability to concentrate on one feature of a situation while neglecting all other aspects. Causality is based on the sequence of events, one event ordinarily following another. Non-reversibility refers to the inability of preschoolers to reverse their operations. They are only able to think forward, not retrace or reverse their thought processes.
A nurse assisting with data collection is preparing to auscultate for bowel sounds. The nurse should use which technique?
- A. Begin in the right lower quadrant.
- B. Use the bell end of the stethoscope.
- C. Hold the stethoscope lightly against the skin.
- D. Listen for at least 5 minutes before deciding that bowel sounds are absent.
Correct Answer: A
Rationale: To auscultate for bowel sounds, the nurse should use the diaphragm end piece of the stethoscope as bowel sounds are relatively high pitched. The stethoscope should be held lightly against the skin to avoid stimulating more bowel sounds. The nurse should begin in the right lower quadrant at the ileocecal valve, where bowel sounds are normally present. It is recommended to listen for 5 minutes before deciding that bowel sounds are absent to ensure a thorough assessment. Choice B is incorrect because the bell end is used for low-pitched sounds such as heart sounds. Choice C is incorrect as holding the stethoscope firmly and deeply can cause unnecessary bowel sound stimulation. Choice D is incorrect as listening for 1 minute is insufficient to determine the presence or absence of bowel sounds.
When a nurse-midwife, performing a vaginal examination of a client who suspects that she is pregnant, documents the presence of the Chadwick sign, what does this indicate?
- A. That the cervix appears violet
- B. That cervical softening is present
- C. A positive sign of pregnancy
- D. A thinning of the cervix
Correct Answer: A
Rationale: The correct interpretation of the Chadwick sign is that the cervix appears violet in color. This sign is a probable sign of pregnancy, characterized by the violet coloration of the cervix due to increased vascularity of the pelvic organs. It is not a definitive positive sign of pregnancy but rather a probable one. Choices B and D are incorrect as cervical softening is known as the Goodell sign, and thinning of the cervix is referred to as the Hegar sign. These signs are also probable signs of pregnancy, but they do not specifically indicate the Chadwick sign.
When working with multicultural populations, the nurse should consider all of the following when planning care for a client with an altered sexuality pattern except:
- A. some Hispanic and Native-American cultures are very open when discussing sexuality.
- B. some cultures view the postpartum period as a state of impurity.
- C. some women in the African-American culture view childbearing as a validation of their femaleness.
- D. some Native-American women believe monthly menstruation maintains physical well-being and harmony.
Correct Answer: A
Rationale: When working with multicultural populations, it is essential to understand cultural variations in beliefs and practices related to sexuality. While it is true that some cultures view the postpartum period as a state of impurity and that some women in the African-American culture view childbearing as a validation of their femaleness, the statement 'some Hispanic and Native-American cultures are very open when discussing sexuality' is incorrect. In reality, many cultures, including Hispanic and Native-American cultures, are sometimes hesitant to discuss sexuality. For example, some Navajos, Hispanics, and Orthodox Jews may consider the postpartum period as impure, leading to seclusion of women until the end of bleeding, marked by a ritual bath. Additionally, many Native-American women believe in the importance of monthly menstruation for physical well-being and harmony. Therefore, the statement about Hispanic and Native-American cultures being very open about discussing sexuality is not accurate in the context of working with multicultural populations.
A nurse demonstrates the procedure for bathing a newborn to a new mother. The next day, the nurse watches as the mother bathes the infant. The nurse determines that the mother is performing the procedure correctly if the mother performs which action?
- A. Uses a cotton-tipped swab to carefully clean inside the infant's nose
- B. Uncovers only the body part being washed
- C. Washes the diaper area first
- D. Washes the infant's chest first
Correct Answer: B
Rationale: When bathing a newborn, it is crucial to follow a specific sequence for thorough cleaning and safety. The correct sequence includes starting with the eyes and face, then moving to the external ear, areas behind the ears, neck, hands, arms, legs, and finally the diaper area. Keeping the infant warm is essential, so only the body part being washed should be uncovered. Using a cotton-tipped swab to clean inside the infant's nose is not recommended due to the risk of injury if the infant moves suddenly. Washing the diaper area first is incorrect as it should be done towards the end of the bath to prevent contamination. Washing the infant's chest first is also incorrect as it deviates from the recommended bathing sequence for a newborn.