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At 40-weeks gestation, a client presents to the obstetrical floor with spontaneous rupture of amniotic membranes at home, in active labor, and feeling the urge to push. What information should the nurse prioritize obtaining?
- A. Color and consistency of fluid.
- B. Estimated amount of fluid.
- C. Any odor noted at the rupture of membranes.
- D. Time of membrane rupture.
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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An infant with tetralogy of Fallot becomes acutely cyanotic and hyperneic. Which action should the nurse implement first?
- A. Place the infant in a knee-chest position.
- B. Administer morphine sulfate.
- C. Start intravenous fluids.
- D. Provide 100% oxygen by face mask.
Correct Answer: A
Rationale: In a tetralogy of Fallot situation, placing the infant in a knee-chest position is the initial priority to help increase systemic vascular resistance, which reduces the right-to-left shunt and improves oxygenation. This position can assist in optimizing oxygen levels before considering other interventions.
The caregiver observes a mother giving her 11-month-old ferrous sulfate (iron drops), followed by 2 ounces of orange juice. What should the caregiver do next?
- A. Tell the mother to follow the iron drops with infant formula instead of orange juice.
- B. Suggest placing the iron drops in the orange juice and then feeding the infant.
- C. Instruct the mother to feed the infant nothing for 30 minutes after giving the iron drops.
- D. Give the mother positive feedback about the way she administered the medication.
Correct Answer: D
Rationale: The high vitamin C content in orange juice aids in the absorption of iron. Providing positive feedback to the mother for administering the iron drops with orange juice is appropriate as it enhances iron absorption, benefiting the infant. Encouraging and acknowledging correct medication administration can help reinforce good practices and build confidence in the caregiver.
A new mother calls the nurse stating that she wants to start feeding her 6-month-old child something besides breast milk, but is concerned that the infant is too young to start eating solid foods. How should the nurse respond?
- A. Advise the mother to wait at least another month before starting any solid foods.
- B. Instruct the mother to offer a few spoons of 2 or 3 pureed fruits at each meal.
- C. Reassure the mother that the infant is old enough to eat iron-fortified cereal.
- D. Encourage the mother to schedule a developmental assessment of the infant.
Correct Answer: C
Rationale: At 6 months, infants are generally ready to start eating iron-fortified cereals as their iron stores begin to deplete. Introducing iron-fortified cereals at this age helps meet the infant's nutritional needs, particularly for iron, which becomes deficient as the infant's iron reserves diminish. It is a safe and appropriate first food to introduce to infants around 6 months of age, along with continued breastfeeding or formula feeding.
A client who delivered vaginally 2 days ago states that she wants to resume using her diaphragm for birth control. What information should you share with her?
- A. The most effective form of contraception is a diaphragm.
- B. The diaphragm must be refitted after childbirth.
- C. Vaseline lubricant can be used when inserting the diaphragm.
- D. The diaphragm should be inserted 2 to 4 hours before intercourse.
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A client at 32-weeks gestation comes to the prenatal clinic with complaints of pedal edema, dyspnea, fatigue, and a moist cough. Which question is most important for the LPN/LVN to ask this client?
- A. Which symptom did you experience first?
- B. Are you eating large amounts of salty foods?
- C. Have you visited a foreign country recently?
- D. Do you have a history of rheumatic fever?
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.