Nokea
The client who is scheduled for a nonstress test (NST) asks the nurse to explain the purpose of the test. Which of the following is the correct response?
- A. The purpose of the NST is to assess the fetal CNS.
- B. The purpose of the NST helps to determine gestational age.
- C. The purpose of the NST is to determine fetal lie.
- D. The purpose of the NST is to determine fetal breathing.
Correct Answer: A
Rationale: The correct answer is A: The purpose of the NST is to assess the fetal CNS. The nonstress test (NST) evaluates the fetal CNS by measuring the fetal heart rate in response to fetal movement. This test assesses the overall well-being of the fetus by monitoring for accelerations in the heart rate, indicating a healthy CNS. Choices B, C, and D are incorrect because the NST is not used to determine gestational age, fetal lie, or fetal breathing. The primary focus of the NST is to evaluate the fetal CNS function through monitoring the fetal heart rate patterns.
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A nurse is reinforcing teaching given to the parent of a 1-year-old child who has had a high temperature, vomiting, and diarrhea for 48 hr. The child has sunken eyes and cracked lips. Which of the following should the nurse tell the parent?
- A. Give the infant applesauce and rice cereal because these have been found to have high nutritional value.
- B. Encourage the child to take sips of chicken or beef broth because they will replace the fluid losses your child is experiencing.
- C. Give the infant oral rehydration solutions that are available commercially. They replace some of the electrolytes lost through vomiting.
- D. Give the child nothing by mouth for 4 hr. Once the vomiting has decreased you can introduce sips of clear water.
Correct Answer: C
Rationale: Oral rehydration solutions effectively replace fluids and electrolytes lost due to vomiting and diarrhea.
A client comes to the clinic to confirm that she is pregnant. Her last menstrual period was January 31st. According to Naegele's rule, when should the client expect to deliver?
- A. November 31
- B. December 7
- C. November 7
- D. December 24
Correct Answer: C
Rationale: The correct answer is C: November 7. Naegele's rule estimates the due date by adding 7 days to the first day of the last menstrual period (LMP), subtracting 3 months, and adding 1 year. LMP is January 31, so adding 7 days gives February 7. Subtracting 3 months gives November 7. Other choices are incorrect as there is no November 31, December 7 is too far ahead, and December 24 is also too far from the estimated due date.
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 is initiating a plan of care for a toddler who is hospitalized. Which of the following instructions is important to communicate to the nursing assistant?
- A. Have the toddler dress himself.
- B. Offer the toddler finger foods for snacks.
- C. Provide opportunities to share toys with others.
- D. Ask the child simple yes or no questions.
Correct Answer: B
Rationale: The correct answer is B: Offer the toddler finger foods for snacks. This instruction is important to communicate to the nursing assistant because toddlers are at risk for choking on certain foods due to their developing chewing and swallowing abilities. Finger foods are safer for toddlers to eat as they are easier to manage and reduce the risk of choking.
Other choices are incorrect because:
A: Having the toddler dress himself may not be appropriate as toddlers may need assistance and supervision due to their limited motor skills.
C: Providing opportunities to share toys with others is important for social development but is not as critical as ensuring the toddler's safety during meal times.
D: Asking the child simple yes or no questions is a good communication strategy but not as essential for the toddler's safety during snack times.
A nurse is performing a physical assessment of a newborn. Which of the following clinical findings should the nurse expect? (Select all that apply).
- A. Heart Rate 154/min
- B. Axillary temperature 96.8 F
- C. Respiratory rate 58/min
- D. Length 43 cm (16.9in)
Correct Answer: A,B,C,D
Rationale: The correct answer is A, B, C, and D.
1. Heart rate of 154/min is expected in a newborn, indicating normal cardiac function.
2. Axillary temperature of 96.8 F is within the normal range for a newborn.
3. Respiratory rate of 58/min is expected due to the newborn's immature respiratory system.
4. Length of 43 cm (16.9 in) falls within the normal range for a newborn's size.
Incorrect choices are not applicable due to lack of details, but in general, incorrect options would have included values outside the normal range for a newborn's physical assessment.