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As a nurse providing anticipatory guidance to parents of newborns, for which reason would you advise against allowing young siblings to feed an infant?
- A. Increased risk of aspiration
- B. Increased risk of mouth injury
- C. increased risk of bowel obstruction
- D. Increased risk of vomiting
Correct Answer: A
Rationale: Young children may not properly handle the infant, increasing the risk of aspiration.
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A new mother asks the nurse why newborns receive an injection of vit. K after delivery. What will be the best response from the nurse?
- A. Newborns are given vit K to help with the digestion to help them absorb fat soluble vitamins
- B. Newborns are given vit K and erythromycin ointment to help prevent ophthalmia neonatorum
- C. Newborns lack the intestinal flora needed to produce vit K, so it is given to prevent bleeding episodes
- D. This vitamin substitutes for vitamin C and newborns will strengthen their immune system
Correct Answer: C
Rationale: Vitamin K is essential for clotting and prevents hemorrhagic disease.
To which client is it most appropriate to recommend the intrauterine device (IUD)?
- A. Unmarried, 22-year-old, recent college graduate.
- B. Married, 24-year-old, G0 P0000.
- C. Unmarried, 25-year-old, history of chlamydia.
- D. Married, 26-year-old, G3 P2102.
Correct Answer: D
Rationale: IUDs are ideal for women in stable relationships with no history of PID.
What response by a client indicates effective postvasectomy teaching?
- A. I will measure my urinary output for two days.
- B. I will ejaculate the same amount of semen as I did before the surgery.
- C. I will refrain from having an erection until next week.
- D. I will irrigate the wound twice today and once more tomorrow.
Correct Answer: B
Rationale: Semen volume remains unchanged after vasectomy.
The nurse is monitoring a client with gestational hypertension. What symptom requires immediate intervention?
- A. Weight gain of 1 pound in a week.
- B. Slight swelling of the hands and feet.
- C. Severe headache and vision changes.
- D. Blood pressure of 135/85 mmHg.
Correct Answer: C
Rationale: Severe headache and vision changes may indicate preeclampsia and require immediate evaluation.
What nursing intervention is appropriate for a woman diagnosed with syphilis?
- A. Council the woman about how to live with a chronic infection.
- B. Question the woman regarding symptoms of other sexually transmitted infections.
- C. Assist the primary health care practitioner with cryotherapy procedures.
- D. Educate the woman regarding the safe disposal of menstrual pads.
Correct Answer: B
Rationale: Syphilis often coexists with other STIs, so questioning is important.