Nokea
The health history and physical examination cannot reliably identify all persons infected with HIV or other blood-borne pathogens. Which infection control practice should the nurse use when providing eye prophylaxis to a term newborn?
- A. Wear gloves.
- B. Wear mouth, nose, and eye protection.
- C. Wear a mask.
- D. Wash the hands after medication administration.
Correct Answer: A
Rationale: Standard precautions require the use of gloves when providing eye prophylaxis to a newborn.
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A nurse is assessing a client who gave birth 1 week ago. The client states, 'I don't know what's wrong. I love my baby, but I feel so let down and I seem to cry for no reason.' The nurse should identify that the client is experiencing which of the following emotional responses to birth?
- A. Postpartum depression
- B. Taking-in phase
- C. Postpartum blues
- D. Taking-hold phase
Correct Answer: C
Rationale: Postpartum blues is a common emotional response occurring within the first two weeks postpartum. Symptoms include mood swings, tearfulness, and sadness due to hormonal changes. It is self-limiting, unlike postpartum depression, which is more severe and persistent.
Maternity nurses can enhance communication among health care providers by using the SBAR technique. The acronym SBAR stands for what?
- A. Situation, background, assessment, recommendation
- B. Situation, baseline, assessment, recommendation
- C. Subjective, background, analysis, recommendation
- D. Subjective, background, analysis, review
Correct Answer: A
Rationale: SBAR stands for Situation, Background, Assessment, and Recommendation, which is a communication technique for providing important information.
Which condition, not uncommon in pregnancy, is likely to require careful medical assessment during the puerperium?
- A. Varicosities of the legs
- B. Carpal tunnel syndrome
- C. Periodic numbness and tingling of the fingers
- D. Headaches
Correct Answer: D
Rationale: Headaches in the postpartum period can have a number of causes, some of which deserve medical attention.
What are the most common causes for subinvolution of the uterus?
- A. Postpartum hemorrhage and infection
- B. Multiple gestation and postpartum hemorrhage
- C. Uterine tetany and overproduction of oxytocin
- D. Retained placental fragments and infection
Correct Answer: D
Rationale: Subinvolution is the failure of the uterus to return to a nonpregnant state. The most common causes are retained placental fragments and infection.
In which step of the nursing process does the nurse determine the appropriate interventions for the identified nursing diagnosis?
- A. Planning
- B. Evaluation
- C. Assessment
- D. Intervention
Correct Answer: A
Rationale: In the nursing process, planning is the step where the nurse determines the appropriate interventions for the identified nursing diagnosis. Firstly, after assessing the patient's needs (Assessment), the nurse analyzes the data to identify nursing diagnoses. Next, in the Planning step, the nurse sets goals, establishes priorities, and decides on specific interventions to address the nursing diagnoses. This step involves developing a comprehensive care plan tailored to the individual patient's needs. Evaluation comes after the interventions are implemented to assess the effectiveness of the care provided. The Intervention step involves carrying out the planned interventions. Thus, the correct answer is A: Planning.