Nokea
An infant delivered vaginally by an HIV-positive mother is admitted to the newborn nursery. What intervention should the healthcare provider perform first?
- A. Bathe the infant with an antimicrobial soap.
- B. Measure the head and chest circumference.
- C. Obtain the infant's footprints.
- D. Administer vitamin K (AquaMEPHYTON).
Correct Answer: A
Rationale: The initial intervention should be to bathe the infant with an antimicrobial soap to reduce the risk of HIV transmission from maternal fluids. This immediate action helps minimize potential exposure to the virus and promotes infection control practices in the care of infants born to HIV-positive mothers.
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A mother calls the school nurse to report that her preschool-aged child was bitten by a tick during a school outing last week. The mother removed the tick and flushed it down the toilet. What action should the school nurse take?
- A. Refer the mother to the Centers for Disease Control and Prevention.
- B. Report the incident to the school principal.
- C. Culture the bite site when the child returns to school.
- D. Schedule a test for Lyme disease if a rash appears.
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A client is admitted to the postpartum unit and tells the nurse she had rheumatic fever as a child, which resulted in some 'heart damage'. The nurse knows that this client is at particular risk for developing heart failure during the immediate postpartum period. Based on the client's history, which nursing problem has the highest priority?
- A. Nausea and vomiting.
- B. Risk for infection.
- C. Sleep deprivation.
- D. Fluid volume excess.
Correct Answer: D
Rationale: Fluid volume excess is a priority concern in this client, as heart damage from rheumatic fever can impair the heart's ability to manage increased blood volume postpartum, leading to potential heart failure. Monitoring and managing fluid volume status are crucial to prevent complications in this high-risk client.
What maternal behavior is typically observed when a new mother first receives her infant?
- A. She eagerly reaches for the infant, undresses the infant, and examines the infant completely.
- B. Her arms and hands receive the infant and she then traces the infant's profile with her fingertips.
- C. Her arms and hands receive the infant and she then cuddles the infant to her own body.
- D. She eagerly reaches for the infant and then holds the infant close to her own body.
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The client is admitted in active labor with a cervix that is 3 cm dilated, 50% effaced, and the presenting part at 0 station. An hour later, the client expresses the need to go to the bathroom. Which action should the nurse implement first?
- A. Palpate the client's bladder.
- B. Check the pH of the vaginal fluid.
- C. Review the fetal heart rate pattern.
- D. Determine cervical dilation.
Correct Answer: D
Rationale: The nurse should prioritize determining cervical dilation as it helps in assessing the progress of labor and ensures it is safe for the client to move. Changes in cervical dilation may indicate the advancement of labor, warranting appropriate interventions or restrictions on movement to prevent complications.
A new mother is having trouble breastfeeding her newborn son. He is making frantic rooting motions and will not grasp the nipple. What intervention would be most helpful to this mother?
- A. Ask the mother to stop feeding, comfort the infant, and then assist the mother to help the baby latch on.
- B. Use a nipple shield to help the baby latch on.
- C. Try a different breastfeeding position.
- D. Have another person help the mother with breastfeeding.
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.