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Before administering the hepatitis B vaccine to a newborn infant, what should the nurse do?
- A. Request parental consent to administer the vaccine.
- B. Check the infant for jaundice.
- C. Check the infant's temperature.
- D. Obtain parental consent to administer the vaccine.
Correct Answer: D
Rationale: Before administering the hepatitis B vaccine to a newborn infant, the nurse must obtain parental consent. Hepatitis B vaccine is typically given at birth, 1 month, and 6 months of age. Checking the infant for jaundice, checking the temperature, and requesting a hepatitis blood screen are unnecessary in this context. Parental consent is crucial for any medical intervention involving minors.
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When planning for the physical assessment of the woman, the nurse ensures that which occurs?
- A. The woman is examined by a female health care provider.
- B. The woman's husband remains in the examining room at all times.
- C. The woman is examined without any other people in the examining room.
- D. Written permission is obtained from the woman to obtain subjective health data.
Correct Answer: A
Rationale: In many cultures, including Muslim, Hindu, and Latino, modesty is important, and exposure of a woman's genitals to men is considered demeaning. To respect the patient's cultural beliefs and modesty, it is best for a female health care provider to perform the examination. This practice helps to ensure the patient's comfort and adherence to cultural norms. Having the woman examined without any other people in the room (Choice C) may not address the cultural sensitivity required for this situation. Having the woman's husband remain in the examining room at all times (Choice B) may not align with the patient's cultural preferences and may cause discomfort. Written permission from the woman to obtain subjective health data (Choice D) is not directly related to ensuring a culturally sensitive physical assessment in this context.
A pregnant client is scheduled to undergo a transabdominal ultrasound, and the nurse provides information to the client about the procedure. The nurse provides which information?
- A. The procedure typically takes 10 to 30 minutes.
- B. She may need to drink fluids before the test and may not void until the test has been completed.
- C. A probe coated with gel will be inserted into the vagina.
- D. She will be positioned on her back, with her head elevated and turned slightly to one side.
Correct Answer: B
Rationale: The correct answer is that the client may need to drink fluids before the test and may not void until the test has been completed. For a transabdominal ultrasound, the woman is positioned on her back with her head elevated and turned slightly to one side to prevent supine hypotension. A wedge or rolled blanket is placed under one hip to help her maintain this position comfortably. If a full bladder is necessary, the woman is instructed to drink several glasses of clear fluid 1 hour before the test and told that she should not void until the test has been completed. Warm mineral oil or transmission gel is spread over her abdomen, and the sonographer slowly moves a transducer over the abdomen to obtain a picture. The procedure typically takes 10 to 30 minutes, making choice A incorrect. Choice C is incorrect because a probe is not inserted into the vagina for a transabdominal ultrasound. Choice D is incorrect because the woman is positioned on her back with her head elevated and turned slightly to one side, not specifically on her back.
A nurse assisting with data collection plans to assess tactile (vocal) fremitus. The nurse performs this by using which technique?
- A. Palpating for symmetric chest expansion
- B. Auscultating the breath sounds over the trachea and larynx
- C. Auscultating the breath sounds over the peripheral lung fields
- D. Palpating the thorax, comparing vibrations from side to side as the client repeats the word 'ninety-nine'
Correct Answer: D
Rationale: To assess tactile (vocal) fremitus, the nurse palpates the thorax and compares vibrations from side to side as the client repeats the word 'ninety-nine.' This technique helps in evaluating the intensity and symmetry of vibrations felt. Palpating for symmetric chest expansion involves assessing the expansion of the chest during breathing by placing hands on the anterolateral wall. Auscultating the breath sounds over the trachea and larynx is done to assess bronchial breath sounds, while auscultating over the peripheral lung fields is used to assess vesicular breath sounds.
A client is taught about healthy dietary measures and the MyPlate food plan. How many of his grains should be whole grains according to the MyPlate food plan?
- A. One-quarter
- B. One-third
- C. One-half
- D. Two-thirds
Correct Answer: C
Rationale: The correct answer is 'One-half.' According to the MyPlate food plan, at least half of the grains consumed daily should be whole grains. This ensures a well-balanced and healthy diet. Choices A, B, and D are incorrect because they do not align with the dietary recommendation provided by the MyPlate food plan. One-quarter, one-third, and two-thirds do not represent the appropriate proportion of whole grains as advised by the plan, which emphasizes the importance of including a significant portion of whole grains in one's diet.
A nurse calculates a newborn infant's Apgar score 1 minute after birth and determines that the score is 6. What is the most appropriate action for the nurse to take?
- A. Initiate cardiopulmonary resuscitation
- B. Gently stimulate the infant by rubbing his back while administering oxygen
- C. Recheck the score in 5 minutes
- D. Provide no action except to support the infant's spontaneous efforts
Correct Answer: B
Rationale: The Apgar score is a method for rapidly evaluating an infant's cardiorespiratory adaptation after birth. The nurse assigns scores in five areas: heart rate, respiratory effort, muscle tone, reflex response, and color, totaling the scores. A score of 8 to 10 requires no action other than supporting the infant's spontaneous efforts and observation. A score of 4 to 7 indicates the need to gently stimulate the infant by rubbing his back while administering oxygen. If the score is 1 to 3, the infant requires resuscitation. Therefore, in this scenario with an Apgar score of 6, the correct action is to gently stimulate the infant by rubbing his back while administering oxygen. Initiating cardiopulmonary resuscitation would be excessive at this point, and rechecking the score in 5 minutes may delay necessary interventions. Providing no action except to support the infant's spontaneous efforts is insufficient for a score of 6, indicating the need for stimulation and oxygen administration.