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During the assessment of a newborn, it is most important for the nurse to report a:
- A. Temperature of 97.7 degrees Fahrenheit
- B. Pale pink, rust-colored stain in the diaper
- C. Heart rate that drops to 120 beats/min
- D. Breathing pattern that is diaphragmatic with sternal retractions
Correct Answer: D
Rationale: Sternal retractions indicate respiratory difficulty.
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What is the priority nursing intervention for a newborn with a low Apgar score of 4 at 1 minute?
- A. Place the baby in skin-to-skin contact with the mother
- B. Administer oxygen and stimulate the baby
- C. Delay interventions and reassess in 5 minutes
- D. Begin chest compressions immediately
Correct Answer: B
Rationale: A low Apgar score indicates poor adaptation; oxygen improves function.
For which conditions is the lactational amenorrhea method of birth control effective?
- A. Being less than 6 months postpartum.
- B. Being amenorrheic since delivery of the baby.
- C. Supplementing with formula no more than once per day.
- D. Losing less than 10% of weight since delivery.
Correct Answer: A
Rationale: Lactational amenorrhea is effective only within 6 months postpartum if exclusively breastfeeding.
Relaxation of muscles in labor provides many benefits. What is one benefit of this technique in labor?
- A. Relaxation will prevent a cesarean section.
- B. Relaxation of the pelvic floor helps in pushing the fetus in the second stage.
- C. Relaxation of the abdomen ensures an unmedicated birth.
- D. Relaxation causes the contractions to decrease in strength.
Correct Answer: B
Rationale: Relaxing the pelvic floor facilitates smoother fetal descent during the second stage of labor.
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.
Why is it important for nurses to approach the topic of sexual history with sensitivity and create a nonjudgmental and confidential environment?
- A. to increase patient satisfaction with the health-care provider
- B. to ensure that patients feel comfortable and supported during the assessment
- C. to promote healthy sexual behaviors among patients
- D. to comply with health-care regulations and standards
Correct Answer: B
Rationale: