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After the RN is finished the initial assessment of a newborn baby and after the initial bonding between the newborn and the mother has taken place in the delivery room, the RN will bring the newborn to the well-baby nursery. Before the newborn is taken from the delivery room and brought to the well-baby nursery, the RN makes sure that which of the following interventions was completed?
- A. The physician verifies the exact time of birth.
- B. The nurse counts the instruments and sponges with the scrub nurse.
- C. The nurse instills prophylactic ointment in the conjunctival sacs of the newborn's eyes.
- D. The nurse makes sure the mother and her newborn have been tagged with identical bands.
Correct Answer: D
Rationale: Tagging the mother and infant with identical bands ensures proper identification, preventing mix-ups and ensuring safety.
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A client with sickle cell disease is admitted in active labor. Which nursing intervention would be most helpful in preventing a sickling crisis?
- A. Obtaining blood pressures every two hours
- B. Administering pain medication every three hours as ordered
- C. Monitoring arterial blood gas results
- D. Administering IV fluids at ordered rate of 200 mL/hr
Correct Answer: D
Rationale: IV fluids at 200 mL/hr prevent dehydration, a trigger for sickling crises, by maintaining hydration and blood flow. BP monitoring (A), pain medication (B), and ABGs (C) are supportive but less directly preventive.
A 65-year-old client is admitted after a stroke. Which nursing intervention would best improve tissue perfusion to prevent skin problems?
- A. Assessing the skin daily for breakdown
- B. Massaging any erythematous areas on the skin
- C. Changing incontinence pads as soon as they become soiled with urine or feces
- D. Performing range-of-motion exercises and turning and repositioning the client
Correct Answer: D
Rationale: Performing range-of-motion exercises and turning/repositioning enhances blood flow to tissues, reducing the risk of pressure ulcers by relieving pressure points. Assessing skin (A) is monitoring, not an intervention to improve perfusion. Massaging erythematous areas (B) can worsen tissue damage. Changing pads (C) prevents irritation but doesn’t directly improve perfusion.
A client is admitted to the labor and delivery unit complaining of vaginal bleeding with very little discomfort. The nurse's first action should be to:
- A. Assess the fetal heart tones
- B. Check for cervical dilation
- C. Check for firmness of the uterus
- D. Obtain a detailed history
Correct Answer: A
Rationale: Vaginal bleeding in labor may indicate placental abruption or previa both of which threaten fetal well-being. Assessing fetal heart tones is the first action to ensure fetal stability before further evaluation.
A client with a history of a bone marrow transplant is receiving immunosuppressive therapy. The nurse should monitor the client for:
- A. Infection
- B. Hypotension
- C. Hyperglycemia
- D. Hair loss
Correct Answer: A
Rationale: Immunosuppressive therapy post-bone marrow transplant increases infection risk due to suppressed immunity. Hypotension, hyperglycemia, and hair loss are less immediate concerns.
A female client is seeking counseling for personal problems. She admits to being very unhappy lately at both home and work. During the nursing assessment, she uses many defense mechanisms. Which statement or action made by the client is an example of adaptive suppression?
- A. I did not get the raise because my boss does not like me.'
- B. I felt a lump in my breast 2 weeks ago. I put off getting it checked until after my sister's wedding.'
- C. My son died 3 years ago. I still cannot bring myself to clean out his room.'
- D. My husband told me this morning that he wants a divorce. I am upset, but I cannot discuss the matter with him until after my company's board meeting today.'
Correct Answer: D
Rationale: This statement is an example of adaptive rationalization. She is coping with her disappointment by rationalizing. This is adaptive because no harm is done to self or others. It is used to protect her ego. This is an example of maladaptive suppression. She is suppressing the seriousness of the lump. It is maladaptive because delaying treatment will cause harm to her. The client's actions are an example of maladaptive denial. She is denying her son's death by not facing his possessions. Until she faces his death, she cannot face reality. This is an example of adaptive suppression. She realizes the impact of her husband's statement but delays discussion until she can devote her full attention to the matter.