Nokea
What is the priority nursing care associated with oxytocin infusion?
- A. Monitoring uterine response (don't want it to ruptur
- C. Measuring urinary output
- D. Check cervical dilation
Correct Answer: A
Rationale: The correct answer is A because monitoring uterine response is crucial when administering oxytocin infusion to prevent uterine hyperstimulation and rupture. This involves assessing contraction frequency, duration, and strength. Measuring urinary output (choice C) is important for overall fluid balance but not directly related to oxytocin infusion. Checking cervical dilation (choice D) is not a priority when administering oxytocin. Choice B is incomplete.
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The nurse assures the breastfeeding mother that she will know that her infant is getting an adequate supply of breast milk if the infant gains weight and:
- A. Rarely sucks on a pacifier.
- B. Ha several hard stools daily
- C. Voids 6 or more times a day
- D. Awakens to feed every 4 hours
Correct Answer: C
Rationale: The correct answer is C: Voids 6 or more times a day. Adequate breast milk intake is indicated by frequent urination (6 or more times/day) in infants. This shows the infant is hydrated and receiving enough milk. The other choices are incorrect because A) pacifier use doesn't indicate milk supply, B) hard stools can be a sign of dehydration or other issues, and D) feeding every 4 hours is a general guideline but not a definitive indicator of milk supply.
A woman asks about the side effects of the contraceptive implant. Which of the following should the nurse include in the discussion?
- A. The implant will cause heavy menstrual bleeding.
- B. The implant may cause irregular bleeding patterns, including light spotting.
- C. The implant can cause weight gain.
- D. The implant may cause hair loss.
Correct Answer: B
Rationale: The correct answer is B because irregular bleeding patterns, including light spotting, are a common side effect of the contraceptive implant due to hormonal changes. This is important for the woman to be aware of to manage her expectations. Choice A is incorrect as the implant typically leads to lighter periods or no periods at all. Choice C is incorrect as weight gain is not a common side effect of the implant. Choice D is also incorrect as hair loss is not typically associated with the contraceptive implant.
A meconium stool can be differentiated from a transitional stool in the newborn because the meconium stool is
- A. Passed in first 12-24h of life
- B. Seen at 3 days
- C. Residue of a milk curd
- D. Lighter in color and looser in consistency
Correct Answer: A
Rationale: The correct answer is A because meconium stool is typically passed within the first 12-24 hours of life in newborns. Meconium is the earliest stool passed by a newborn and is composed of materials ingested while in the womb. Choices B, C, and D are incorrect because transitional stool is typically seen at 3 days, meconium is not a residue of milk curd, and meconium is darker in color and stickier in consistency compared to transitional stool.
A nurse is reinforcing teaching about reducing perineal infection with a client following a vaginal delivery. Which of the following should the nurse include in the teaching? (Select all that apply.)
- A. Blot the perineal area dry after cleansing.
- B. Clean the perineal area from front to back.
- C. Perform hand hygiene before and after voiding.
- D. Wash the perineal area using a squeeze bottle of warm water after each voiding.
Correct Answer: A
Rationale: Correct Answer: A - Blot the perineal area dry after cleansing.
Rationale: Blotting the perineal area dry after cleansing helps prevent moisture accumulation, reducing the risk of perineal infection. Moisture can create a favorable environment for bacterial growth and infection. This practice also helps maintain skin integrity and promotes healing post-vaginal delivery.
Summary of other choices:
B: Cleaning the perineal area from front to back is important to prevent introducing fecal bacteria to the urinary tract but is not directly related to reducing perineal infection.
C: Performing hand hygiene before and after voiding is crucial for infection prevention but does not directly address reducing perineal infection.
D: Washing the perineal area using a squeeze bottle of warm water after each voiding can be beneficial for cleanliness but does not specifically address reducing perineal infection like blotting dry after cleansing does.
People in extended families can live together for many reasons. What can the nurse do to provide the best care for a person living with an extended family?
- A. Assume the family is poor and needs information on financial assistance.
- B. Ask the person if they would like the family members to remain in the room during the exam.
- C. Set a limit on who is allowed in the room with the person regardless of the circumstances.
- D. Address the family first then the patient.
Correct Answer: B
Rationale: The correct answer is B because it respects the person's autonomy and preferences by asking if they want family members present during the exam. This approach ensures the person's comfort and privacy while also promoting family involvement in care. Choice A assumes financial need without evidence. Choice C limits family support. Choice D may neglect the person's immediate needs.