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In response to a call for assistance by a client in labor, the nurse notes that a loop of the umbilical cord protrudes from the vagina. What is the priority nursing action?
- A. call the health care provider
- B. check fetal heart load
- C. put the client in knee-chest position
- D. turn the client to the side
Correct Answer: C
Rationale: Immediate action is needed to relieve pressure on the cord, which puts the fetus at risk due to hypoxia. The knee-chest position accomplishes this. The exposed cord is covered with saline-soaked gauze, not reinserted.
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The clinic nurse is caring for several clients during well-child visits. The nurse should recognize which client as being the most at risk for anemia?
- A. 1-month-old infant born at term gestation who exclusively breastfeeds
- B. 2-month-old infant born at preterm gestation who exclusively receives iron-fortified formula
- C. 3-month-old infant born at preterm gestation who is exclusively bottle-fed with breastmilk
- D. 4-month-old infant born at term gestation who breastfeeds and eats iron-fortified infant cereal
Correct Answer: C
Rationale: A preterm infant bottle-fed with breastmilk is most at risk for anemia due to preterm infants' lower iron stores and breastmilk's low iron content. Term breastfed infants (A, D) have adequate stores initially, and iron-fortified formula prevents anemia.
The nurse is caring for a client who had a transurethral resection of the prostate 12 hours ago and is receiving continuous bladder irrigation. The client reports lower abdominal pain rated as an 8 on a scale of 0 to 10. Which of the following actions would be a priority for the nurse to take?
- A. Administer morphine to the client.
- B. Verify when the client had the last flatus or bowel movement.
- C. Administer oxybutynin to the client.
- D. Verify the amount and characteristics of the client's urine output.
Correct Answer: D
Rationale: Severe abdominal pain post-TURP with bladder irrigation suggests possible catheter obstruction or clot formation. Verifying urine output and characteristics is the priority to ensure patency. Morphine , checking bowel movement , or oxybutynin are secondary.
A nurse from the float pool is giving medications on a pediatric unit and is to give medications to a 2-year-old child in room 534, bed B. The child in that room does not have an identification band. What is the best action for the nurse to take?
- A. Ask the child what his name is
- B. Give the medication to the child in room 534, bed B
- C. Refuse to give the medication
- D. Ask the adults beside the bed the name of the child in that bed
Correct Answer: C
Rationale: Refusing to give medication without proper identification ensures safety, as a 2-year-old cannot reliably confirm identity.
A woman brings her 6-month-old daughter to a clinic for a checkup and immunizations. The mother tells the nurse that her infant is cranky, has a bad cold, and has not eaten well the last days. She asks if the baby will still be able to get her shots. The child's temperature is 100.8°F. How should the nurse respond?
- A. There is no problem in giving the shots just because your baby has a cold.'
- B. Your baby will have her checkup, but we will wait until her cold is better before giving her shots.'
- C. The shots often make them a little irritable, so we might as well get it all over with at one time.'
- D. I'm not sure why you came today. We need to reschedule the whole appointment for another day when your baby has no symptoms of a cold.'
Correct Answer: B
Rationale: Mild fever and illness contraindicate vaccinations due to potential reduced immune response and difficulty distinguishing vaccine reactions from illness symptoms.
The nurse is caring for a client who has a prescription for clarithromycin 7.5 mg/kg/day PO in 2 divided doses. The client weighs 78 lb. How many mL should the nurse administer for each dose? Record your answer using 1 decimal place.
Correct Answer: 7.5 mL/dose
Rationale: Client weight: 78 lb ÷ 2.2 = 35.45 kg. Dose: 7.5 mg/kg/day × 35.45 kg = 265.875 mg/day ÷ 2 doses = 132.9375 mg/dose. Clarithromycin is typically 250 mg/5 mL. Thus, 132.9375 mg × (5 mL/250 mg) = 2.65875 mL ≈ 2.7 mL/dose.