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Complete the following sentence using the lists of options: The nurse should [option] intramuscular ceftriaxone [purpose].
- A. The nurse should prescribe intramuscular ceftriaxone to decrease the risk of ophthalmia neonatorum in a newborn.
- B. The nurse should identify ceftriaxone as a suitable medication for bacterial infections.
- C. The nurse should use intramuscular ceftriaxone to treat gonorrhea effectively.
- D. The nurse should select intramuscular ceftriaxone for prophylaxis against postpartum infections.
Correct Answer: A
Rationale: Intramuscular ceftriaxone is effective in preventing ophthalmia neonatorum, caused by Neisseria gonorrhoeae. This bacterial prophylaxis inhibits cell wall synthesis, reducing infection transmission from mother to newborn.
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A nurse is assessing a client who gave birth 1 week ago. The client states, 'I don't know what's wrong. I love my baby, but I feel so let down and I seem to cry for no reason.' The nurse should identify that the client is experiencing which of the following emotional responses to birth?
- A. Postpartum depression.
- B. Taking-in phase.
- C. Postpartum blues.
- D. Taking-hold phase.
Correct Answer: C
Rationale: Postpartum blues, characterized by mood swings, crying spells, and irritability, typically resolve within two weeks postpartum and are linked to hormonal changes.
A nurse is assessing a client who is at 31 weeks of gestation. Which of the following findings should the nurse identify as an indication of a potential prenatal complication?
- A. Periodic tingling of fingers.
- B. Absence of clonus.
- C. Leg cramps.
- D. Blurred vision.
Correct Answer: D
Rationale: Blurred vision may result from severe preeclampsia or elevated blood pressure, signifying potential end-organ damage. It requires immediate medical evaluation to prevent progression to eclampsia.
A nurse is assessing a newborn who was born vaginally with vacuum extractor assistance. The nurse notes swelling over the newborn's head that crosses the suture line. The nurse should identify the swelling as which of the following findings?
- A. Nevus flammeus.
- B. Caput succedaneum.
- C. Cephalohematoma.
- D. Erythema toxicum.
Correct Answer: B
Rationale: Caput succedaneum involves swelling of the scalp caused by pressure during delivery, often crossing suture lines due to subcutaneous fluid accumulation, a hallmark distinguishing it from other neonatal head conditions.
A nurse is caring for a client who is postoperative following a mastectomy. The client expresses concern that they will no longer be attractive to their partner. Which of the following actions should the nurse take?
- A. Discourage the client from looking at their breasts.
- B. Recommend a support group for the client to attend.
- C. Tell the client you are so sorry for how devastated they must feel.
- D. Tell the client to focus on their postoperative recovery for now.
Correct Answer: B
Rationale: Recommending a support group provides psychosocial support, enabling clients to share experiences and gain insights from peers, which can alleviate feelings of inadequacy and encourage acceptance of body image changes.
For each body system below, specify the potential manifestations that the client may experience. Match each body system with the potential manifestation.
- A. Nausea
- B. Pain
- C. Headache
- D. Body aches
Correct Answer: D
Rationale: General: Body aches (D) - reflects systemic discomfort. Head, ears, eyes, nose, and throat: Headache (C) - common neurological symptom. Gastrointestinal: Nausea (A) - due to digestive disturbances. Breast: Pain (B) - related to tissue sensitivity or engorgement.