Nokea
Immediately after birth, the nurse places the newborn under a radiant warmer. Which is the primary rationale for the nurse's action?
- A. To facilitate an efficient means of thermoregulation
- B. To facilitate initial assessment by the nurse
- C. To permit the use of the cardiac monitor
- D. To permit close observation by the family members
Correct Answer: A
Rationale: The correct answer is A: To facilitate an efficient means of thermoregulation. Placing the newborn under a radiant warmer helps prevent hypothermia by maintaining the baby's body temperature. Newborns have difficulty regulating their own body temperature initially, so the radiant warmer provides a controlled environment to keep them warm. Choice B is incorrect because the primary reason is not for assessment but for thermoregulation. Choice C is incorrect as a cardiac monitor is not typically needed immediately after birth. Choice D is incorrect as the primary focus is on the newborn's well-being, not family observation.
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A nurse is caring for an infant with a history of vomiting due to gastroenteritis. Which of the following nursing interventions is considered the priority?
- A. Place the infant in a side or semi-reclined position.
- B. Administer oral rehydration and electrolyte therapy.
- C. Administer antiemetic medications as prescribed.
- D. Maintain a high-carbohydrate intake to prevent ketosis.
Correct Answer: A
Rationale: Positioning the infant prevents aspiration, which is the highest priority.
A nurse is providing client/patient education to the mother of an 8-year-old child diagnosed with B-hemolytic streptococci infection (strep throat). The nurse emphasizes the importance of promptly starting and completing the entire course of antibiotics.
- A. alleviate painful swallowing to avoid complications of dehydration and malnutrition'
- B. prevent sinusitis or abscess formation on the pharyngeal or peri tonsillar areas'
- C. reduce the risk of anterior cervical lymphadenopathy'
- D. eliminate organisms that might initiate acute renal failure or rheumatic fever'
Correct Answer: D
Rationale: The correct answer is D. Completing the entire course of antibiotics for strep throat is crucial to eliminate the bacteria completely. Failure to do so may lead to potential complications like acute renal failure or rheumatic fever, which are serious systemic conditions associated with untreated strep infections. This is because streptococcal infections can trigger an immune response that can attack other parts of the body if not fully eradicated.
Choice A is incorrect because while completing the antibiotics may alleviate painful swallowing, the main emphasis should be on preventing systemic complications. Choice B is incorrect as sinusitis or abscess formation are not the primary concerns with strep throat. Choice C is incorrect as reducing anterior cervical lymphadenopathy is not the primary goal of antibiotic treatment for strep throat.
In summary, completing the full course of antibiotics is crucial to eliminate the bacteria and prevent serious complications such as acute renal failure or rheumatic fever.
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 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 caring for a 3-year-old child who is diagnosed with a urinary tract infection (UTI). The parent is concerned about recognizing the signs and symptoms of future UTIs. Which of the following statements made by the parent indicates a correct understanding of the manifestations of a UTI?
- A. I should look for more frequent urination and strong-smelling urine.
- B. My child would have tea-colored urine and puffiness around the eyes.
- C. I should observe for episodes of nausea and less frequent urination.
- D. My child would have pale-colored urine and abdominal tenderness and pain.
Correct Answer: A
Rationale: Frequent urination and strong-smelling urine are classic signs of a UTI.