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During the admission procedure of a 6-year-old, the child states, 'I'm going to have an operation.' Which response is best for the nurse to provide to this child?
- A. Are you scared?
- B. We're going to do everything we can to take very good care of you.
- C. Tell me what an operation is.
- D. I'm glad your mother told you why you were coming to the hospital.
Correct Answer: B
Rationale: In this situation, the most appropriate response for the nurse is to provide reassurance and express care to alleviate the child's anxiety about the upcoming operation. By reassuring the child that everything will be done to take very good care of them, the nurse helps build trust and comfort, creating a positive and supportive environment for the child.
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A multiparous client is involuntarily pushing while being wheeled into the labor triage area. The nurse observes the fetal head presenting at the perineum. Which action should the nurse take?
- A. Support the infant as it emerges.
- B. Review prenatal laboratory results.
- C. Obtain fetal heart tones.
- D. Apply suprapubic pressure.
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The healthcare provider is providing preconception counseling. Which supplement should the provider recommend to help prevent the occurrence of anencephaly?
- A. Folic Acid.
- B. Calcium.
- C. Iron.
- D. Vitamin D.
Correct Answer: A
Rationale: Folic acid supplementation before and during early pregnancy is crucial for reducing the risk of neural tube defects, including anencephaly. Anencephaly is a severe birth defect in which a baby is born without parts of the brain and skull. Folic acid plays a key role in neural tube development and can significantly lower the chances of such defects when taken prior to conception and in early pregnancy.
Which physical assessment data should the nurse consider a normal finding for a primigravida client who is 12 hours postpartum?
- A. Unilateral lower leg pain.
- B. Saturating two perineal pads per hour.
- C. Pulse rate of 56 bpm.
- D. Soft, spongy fundus.
Correct Answer: C
Rationale: A pulse rate of 56 bpm is a normal finding for a primigravida client who is 12 hours postpartum. Bradycardia (pulse rate 50-70 bpm) can be a normal postpartum occurrence due to increased stroke volume and decreased cardiac output after delivery. Unilateral lower leg pain and saturating two perineal pads per hour are not normal findings and require further assessment. A soft, spongy fundus could indicate uterine atony, which is abnormal postpartum.
The client is 30 weeks pregnant and experiencing preterm labor. Which medication should the nurse anticipate administering to promote fetal lung maturity?
- A. Betamethasone (Celestone).
- B. Magnesium sulfate.
- C. Terbutaline (Brethine).
- D. Ampicillin.
Correct Answer: A
Rationale: Betamethasone (Celestone) is the medication of choice to promote fetal lung maturity in cases of preterm labor. It helps accelerate surfactant production in the fetal lungs, reducing the risk of respiratory distress syndrome. Administering betamethasone to the mother can improve the baby's lung function and overall outcome if preterm birth occurs. Magnesium sulfate is commonly used to prevent seizures in preeclampsia or eclampsia. Terbutaline is a tocolytic agent used to suppress preterm labor contractions. Ampicillin is an antibiotic used for various bacterial infections but does not promote fetal lung maturity.
At 14-weeks gestation, a client arrives at the Emergency Center complaining of a dull pain in the right lower quadrant of her abdomen. The LPN/LVN obtains a blood sample and initiates an IV. Thirty minutes after admission, the client reports feeling a sharp abdominal pain and shoulder pain. Assessment findings include diaphoresis, a heart rate of 120 beats/minute, and a blood pressure of 86/48. Which action should the nurse implement next?
- A. Check the hematocrit results.
- B. Administer pain medication.
- C. Increase the rate of IV fluids.
- D. Monitor the client for contractions.
Correct Answer: C
Rationale: The client's symptoms suggest hypovolemic shock, possibly due to an ectopic pregnancy. Increasing IV fluids is crucial to stabilize the client by improving blood pressure and perfusion. This intervention helps address the underlying issue of hypovolemia and supports the client's hemodynamic status, which takes priority in this emergent situation.