Nokea
The LPN/LVN caring for a laboring client encourages her to void at least q2h, and records each time the client empties her bladder. What is the primary reason for implementing this nursing intervention?
- A. Emptying the bladder during delivery is difficult because of the position of the presenting fetal part.
- B. An over-distended bladder could be traumatized during labor as well as prolong the progress of labor.
- C. Urine specimens for glucose and protein must be obtained at certain intervals throughout labor.
- D. Frequent voiding minimizes the need for catheterization, which increases the chance of bladder infection.
Correct Answer: B
Rationale: The primary reason for encouraging the laboring client to void regularly is to prevent an over-distended bladder, which could impede the descent of the fetus, prolong labor, and be at risk for trauma during delivery. Choice A is incorrect because the difficulty in emptying the bladder during delivery is not the main reason for this nursing intervention. Choice C is incorrect as it pertains to obtaining urine specimens for glucose and protein, not the primary reason for encouraging voiding. Choice D is incorrect because although frequent voiding can indeed minimize the need for catheterization, the primary reason is to prevent an over-distended bladder and potential complications.
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A 4-year-old boy presents with a rash and is diagnosed with varicella (chickenpox). What is the most appropriate intervention to manage this condition?
- A. Administer oral acyclovir.
- B. Apply calamine lotion to soothe itching.
- C. Encourage scratching to relieve itching.
- D. Encourage bed rest to avoid spreading the rash.
Correct Answer: B
Rationale: The most appropriate intervention for managing varicella (chickenpox) in a 4-year-old child is to apply calamine lotion to soothe itching. Calamine lotion helps alleviate the itching associated with the chickenpox rash, providing relief to the child. It is important to discourage scratching to prevent complications such as scarring or secondary bacterial infections. Encouraging bed rest can be beneficial for comfort but is not the primary intervention to manage chickenpox.
A breastfeeding infant, screened for congenital hypothyroidism, is found to have low levels of thyroxine (T4) and high levels of thyroid-stimulating hormone (TSH). What is the best explanation for this finding?
- A. The thyroxine level is low because the TSH level is high.
- B. High thyroxine levels do not normally occur in breastfeeding infants.
- C. The thyroid gland does not produce normal levels of thyroxine for several weeks after birth.
- D. The TSH is high because of the low production of T4 by the thyroid.
Correct Answer: D
Rationale: High TSH and low T4 levels indicate that the thyroid gland is not producing enough hormones, which is a sign of congenital hypothyroidism. In this case, the high TSH is a compensatory response by the body to stimulate the thyroid to produce more T4. Choice A is incorrect because TSH does not directly affect T4 levels; rather, it is the other way around where low T4 levels lead to high TSH levels. Choice B is incorrect because high thyroxine levels are not expected in congenital hypothyroidism. Choice C is incorrect as the thyroid gland should be producing normal levels of thyroxine shortly after birth, making this explanation unlikely in the context of congenital hypothyroidism.
Which intervention is most helpful in relieving postpartum uterine contractions or 'afterpains'?
- A. Lying prone with a pillow on the abdomen.
- B. Using a breast pump.
- C. Massaging the abdomen.
- D. Giving oxytocic medications.
Correct Answer: A
Rationale: Lying prone with a pillow on the abdomen is the most helpful intervention in relieving postpartum uterine contractions or 'afterpains.' This position provides counter-pressure and support to the uterus, helping to alleviate discomfort and promote uterine involution. Choice B, using a breast pump, is not effective in relieving afterpains as it focuses on milk expression. Massaging the abdomen (Choice C) may help with discomfort but does not provide the same level of support as lying prone with a pillow. Giving oxytocic medications (Choice D) is not typically the first-line intervention for afterpains unless there are specific medical indications.
During a routine prenatal health assessment for a client in her third trimester, the client reports that she had fluid leakage on her way to the appointment. Which technique should the nurse implement to evaluate the leakage?
- A. Insert a straight urinary catheter to drain the bladder.
- B. Scan the bladder for urinary retention.
- C. Palpate the suprapubic area for fetal head position.
- D. Test the fluid with a nitrazine strip.
Correct Answer: D
Rationale: Testing the fluid with a nitrazine strip is the appropriate technique to differentiate between amniotic fluid and urine. This test helps in determining if the fluid leakage is amniotic fluid, which is crucial for guiding further management and ensuring appropriate care for the client during the third trimester of pregnancy. Inserting a straight urinary catheter to drain the bladder (Choice A) is unnecessary and invasive in this scenario as the concern is fluid leakage, not urinary retention. Scanning the bladder for urinary retention (Choice B) is also not indicated since the client reported fluid leakage, not retention. Palpating the suprapubic area for fetal head position (Choice C) is unrelated to assessing fluid leakage and not the appropriate technique in this situation.
The healthcare provider is preparing to administer phytonadione to a newborn. Which statement made by the parents indicates understanding why the healthcare provider is administering this medication?
- A. Prevent hemorrhagic disorders.
- B. Help an immature liver.
- C. Improve insufficient dietary intake.
- D. Stimulate the immune system.
Correct Answer: A
Rationale: The correct answer is A: 'Prevent hemorrhagic disorders.' Phytonadione (vitamin K) is administered to newborns to prevent hemorrhagic disease by promoting blood clotting. Newborns are born with low levels of vitamin K, which is essential for blood clotting, hence the administration to prevent hemorrhagic disorders. Choice B is incorrect because phytonadione is not given to help an immature liver but to supply vitamin K. Choice C is incorrect as phytonadione is not administered to improve dietary intake but to provide essential vitamin K. Choice D is incorrect as phytonadione does not stimulate the immune system but helps with blood clotting.