Nokea
After the physician performs an amniotomy, the nurse's first action should be to assess the:
- A. Degree of cervical dilation
- B. Fetal heart tones
- C. Client's vital signs
- D. Client's level of discomfort
Correct Answer: B
Rationale: Post-amniotomy, assessing fetal heart tones is critical to detect potential cord prolapse or distress.
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Two Mexican immigrant families live closely together and share goods, services, and childcare. To which of the following family structures does this model correspond?
- A. Kinship network
- B. Binuclear
- C. Nuclear
- D. Extended
Correct Answer: A
Rationale: A kinship network (A) involves close family units sharing resources, typical in some Mexican cultures. Extended (D) is broader, nuclear (C) is single-family, and binuclear (B) involves divorce.
When caring for a client with an anterior cervical discectomy, the nurse should give priority to assessing for post-operative bleeding. The nurse should pay particular attention to:
- A. Drainage on the surgical dressing
- B. Complaints of neck pain
- C. Bleeding from the mouth
- D. Swelling in the posterior neck
Correct Answer: D
Rationale: Swelling in the posterior neck may indicate a hematoma, which can compress the airway or spinal cord, a critical post-operative complication.
A 6-month-old client is admitted with possible intussuception. Which question during the nursing history is least helpful in obtaining information regarding this diagnosis?
- A. Tell me about his pain.
- B. What does his vomit look like?
- C. Describe his usual diet.
- D. Have you noticed changes in his abdominal size?
Correct Answer: C
Rationale: The usual diet is less directly related to diagnosing intussusception compared to symptoms like pain, vomiting, or abdominal changes.
The nurse is caring for a child with Down syndrome. Which characteristics are commonly found in the child with Down syndrome?
- A. Fragile bones, blue sclera, and brittle teeth
- B. Epicanthal folds, broad hands, and transpalmar creases
- C. Low posterior hairline, webbed neck, and short stature
- D. Developmental regression and cherry-red macula
Correct Answer: B
Rationale: Down syndrome is characterized by epicanthal folds, broad hands, and transpalmar creases.
The nurse is caring for a client admitted with acute laryngotracheobronchitis (LTB). Because of the possibility of complete obstruction of the airway, which of the following should the nurse have available?
- A. Intravenous access supplies
- B. Emergency intubation equipment
- C. Intravenous fluid-administration pump
- D. Supplemental oxygen
Correct Answer: B
Rationale: Emergency intubation equipment is essential for LTB due to the risk of airway obstruction requiring immediate intervention.