Nokea
An unlicensed assistive personnel (UAP) reports to the charge nurse that a client who delivered a 7-pound infant 12 hours ago is reporting a severe headache. The client's blood pressure is 110/70 mmHg, respiratory rate is 18 breaths/min, heart rate is 74 beats/min, and temperature is 98.6°F (37°C). What action should the charge nurse implement first?
- A. Notify the healthcare provider of the assessment findings.
- B. Administer analgesics as prescribed.
- C. Increase the client's fluid intake.
- D. Monitor the client's vital signs every hour.
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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Just after delivery, a new mother tells the nurse, 'I was unsuccessful breastfeeding my first child, but I would like to try with this baby.' Which intervention is best for the LPN/LVN to implement first?
- A. Assess the husband's feelings about his wife's decision to breastfeed their baby.
- B. Ask the client to describe why she was unsuccessful with breastfeeding her last child.
- C. Encourage the client to develop a positive attitude about breastfeeding to help ensure success.
- D. Provide assistance to the mother to begin breastfeeding as soon as possible after delivery.
Correct Answer: D
Rationale: The correct intervention is to provide immediate assistance to the mother to begin breastfeeding as soon as possible after delivery. This approach helps initiate bonding and successful breastfeeding. Taking action promptly can address the mother's desire to breastfeed and promote positive outcomes for both the mother and the newborn.
Albumin 25% IV is prescribed for a child with nephrotic syndrome. Which assessment finding indicates to the nurse that the medication is having the desired effect?
- A. Weight gain.
- B. Reduction of fever.
- C. Improved caloric intake.
- D. Reduction of edema.
Correct Answer: D
Rationale: The correct answer is D: Reduction of edema. Albumin helps reduce edema by increasing oncotic pressure, drawing fluid back into the blood vessels. In nephrotic syndrome, there is an abnormal loss of protein in the urine, leading to decreased oncotic pressure and fluid shifting into the interstitial spaces, causing edema. Administering albumin helps restore the oncotic pressure, reducing edema, which is a desirable effect of the medication.
The parents of a 3-year-old boy with Duchenne muscular dystrophy (DMD) ask, 'How can our son have this disease? We are wondering if we should have any more children.' What information should the nurse provide these parents?
- A. This is an inherited X-linked recessive disorder, which primarily affects male children in the family.
- B. The male infant had a viral infection that went unnoticed and untreated, leading to muscle damage.
- C. The lack of the protein dystrophin in the mother can impact the XXX muscle groups of males.
- D. Spinal cord damage due to birth trauma during a breech vaginal birth weakens the muscles.
Correct Answer: A
Rationale: The correct answer is A. Duchenne muscular dystrophy is an X-linked recessive disorder, meaning the gene mutation causing DMD is located on the X chromosome. Males have one X chromosome and one Y chromosome, so if the X chromosome they inherit from their mother carries the mutated gene, they will develop DMD. Females have two X chromosomes, so they are carriers of the gene but are usually not affected by the disease. Therefore, the nurse should explain to the parents that DMD is an inherited X-linked recessive disorder that primarily affects male children in the family.
A primipara has delivered a stillborn fetus at 30 weeks gestation. To assist the parents in the grieving process, which intervention is most important for the nurse to implement?
- A. Provide an opportunity for the parents to hold their infant in privacy.
- B. Assist the couple in completing a request for autopsy.
- C. Encourage the couple to seek family counseling within the next few weeks.
- D. Explain the possible causes of fetal demise.
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A multiparous client with active herpes lesions is admitted to the unit with spontaneous rupture of membranes. Which action should the nurse take?
- A. Obtain blood culture.
- B. Administer penicillin.
- C. Cover lesion with a dressing.
- D. Prepare her for cesarean section.
Correct Answer: D
Rationale: Active herpes lesions at the time of delivery increase the risk of neonatal transmission. The most appropriate action in this scenario is to prepare the client for a cesarean section. A cesarean section is often recommended to reduce the risk of neonatal transmission of herpes simplex virus during delivery, especially when active lesions are present. This intervention helps minimize direct contact between the newborn and the infected genital tract secretions, thereby decreasing the risk of transmission.