Nokea
In a child diagnosed with Tetralogy of Fallot, which of the following is a compensatory mechanism to decrease venous return to the heart?
- A. Squatting
- B. Clubbing
- C. Shortness of breath
- D. Polycythemia
Correct Answer: A
Rationale: Squatting is a compensatory mechanism that decreases venous return (deoxygenated blood) to the heart. This clinical sign is commonly seen in young children with Tetralogy of Fallot, a type of cyanotic heart disease. Squatting helps reduce the workload on the heart by decreasing the amount of deoxygenated blood returning to it.
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A nurse is providing teaching to a client who is at 40 weeks of gestation and has a new prescription for misoprostol. Which of the following instructions should the nurse include in the teaching?
- A. I can administer oxytocin 4 hours after the insertion of the medication
- B. You will need a full bladder prior to the insertion of the medication
- C. Remain in a side-lying position for 15 minutes after the medication is inserted
- D. An antacid will be given 20 minutes prior to the insertion of the medication
Correct Answer: C
Rationale: The correct answer is C: Remain in a side-lying position for 15 minutes after the medication is inserted. This instruction is important because misoprostol can cause uterine contractions leading to potential discomfort or cramping. By remaining in a side-lying position, the client can help the medication remain in the desired location near the cervix, enhancing its effectiveness. This position also helps reduce the risk of the medication leaking out prematurely and ensures optimal absorption.
Choice A is incorrect because oxytocin is not typically administered shortly after misoprostol due to the potential for excessive uterine stimulation. Choice B is incorrect as a full bladder is not necessary for the insertion of misoprostol. Choice D is incorrect as an antacid is not typically required prior to the insertion of misoprostol.
A nurse provided discharge teaching to new parents on how to care for their newborn following circumcision. Which of the following statements by the parents indicates the need for further clarification?
- A. I should not remove the yellow exudate on the end of the penis.
- B. I will clean his penis with each diaper change.
- C. The circumcision will heal completely within a couple of weeks.
- D. I can give him a tub bath in two days.
Correct Answer: D
Rationale: The correct answer is D. Giving the newborn a tub bath in two days after circumcision could increase the risk of infection as the circumcision wound needs time to heal. A sponge bath is recommended until the wound is completely healed. Choice A is correct because yellow exudate is normal during the healing process. Choice B is correct as keeping the area clean is important. Choice C is correct as circumcision typically heals within a couple of weeks.
A client is in the latent stage of labor. Which nursing intervention is most appropriate?
- A. Encourage the client to walk in the hall until membranes rupture
- B. Instruct the client to place her head on her chest and push with the contraction
- C. Teach the client to use the 'pant-blow' method of breathing
- D. Advise the client to eat a light meal consisting of carbohydrates
Correct Answer: A
Rationale: The correct answer is A because encouraging the client to walk in the hall can help progress labor by promoting movement and gravity, potentially aiding in cervical dilation and descent of the fetus. Walking may also provide comfort and distraction from labor discomfort. Choices B and C are incorrect as they are not appropriate actions during the latent stage of labor and can be harmful. Choice D is incorrect because it is not recommended to eat a meal during labor due to the risk of aspiration if anesthesia is needed.
A nurse is holding an infant during a lumbar puncture for a suspicion of meningitis. The infant is in a sitting position with the buttocks at the edge of the table and the neck flexed, and the nurse is immobilizing the infant's arms and legs. Which assessment takes priority during the procedure?
- A. Circulation checks of the lower extremities
- B. Heart rate and crying pattern
- C. Chest expansion and diaphragm excursion
- D. Clarity of spinal fluid and level of consciousness
Correct Answer: C
Rationale: Chest expansion is critical due to the infant's position, which may limit breathing.
A multiparous woman with a history of all vaginal births is admitted to the hospital in labor. After several hours, the client's labor has not progressed and she is getting tired and restless. The decision is made to proceed with cesarean delivery. The nurse recognizes the client's knowledge deficit regarding the surgical delivery and care after birth. Which is the appropriate expected outcome for correction of the client's knowledge deficit? The client will:
- A. Demonstrate appropriate coping mechanisms needed to get through the surgery.
- B. Accept that the type of delivery will not affect the bonding with the baby.
- C. Verbalize understanding about the reason for the unplanned surgery.
- D. Demonstrate decreased anxiety and fear of the unknown.
Correct Answer: C
Rationale: The correct answer is C: Verbalize understanding about the reason for the unplanned surgery. This outcome focuses on the client understanding why the cesarean delivery is necessary, which is crucial for informed decision-making and reducing anxiety. It shows the client comprehends the situation, which is important for her emotional well-being and cooperation during the procedure and postpartum period. Option A is incorrect because coping mechanisms are important but not directly related to knowledge deficit correction. Option B is incorrect as it does not address the client's knowledge deficit but rather focuses on emotional aspects. Option D is incorrect as it addresses anxiety and fear but not the underlying issue of knowledge deficit.