Nokea
The nurse assigns an individual who is an unlicensed assistive personnel (UAP) to care for a client. Which of the following would be appropriate to delegate to this person? Select all that apply.
- A. Changing the perineal pad and reporting the drainage.
- B. Assisting the mother to latch the infant onto the breast.
- C. Checking the location of the fundus prior to ambulating the client.
- D. Reinforcing good hygiene while assisting the client with washing the perineum.
- E. Discussing postpartum depression with the client who is found crying.
- F. Assisting the client with ambulation shortly after delivery.
Correct Answer: A,D,F
Rationale: UAPs can perform tasks like changing pads, reinforcing hygiene, and assisting with ambulation, but tasks requiring clinical judgment (e.g., fundal checks, breastfeeding assistance, or counseling) are reserved for licensed personnel.
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Assessment of a 2-day-old neonate delivered at 34 weeks' gestation reveals absent apical pulse left of the midclavicular line, cyanosis, grunting, and diminished breath sounds. The nurse should first:
- A. Consult with health care provider to obtain a chest x-ray.
- B. Reposition the neonate and then assess if the grunting and cyanosis resolve.
- C. Begin oxygen administration at 6-8 L via mask.
- D. Obtain a complete blood count to determine infection.
Correct Answer: A
Rationale: These symptoms suggest a serious condition like dextrocardia or pneumothorax, and consulting for a chest x-ray is the priority to confirm the diagnosis.
A primiparous client diagnosed with postpartum depression at 2 weeks postpartum asks about treatment options. The nurse should include:
- A. Immediate hospitalization.
- B. Counseling and possible medication.
- C. Discontinuing breastfeeding.
- D. Limiting family support to reduce stress.
Correct Answer: B
Rationale: Counseling and medication are standard treatments for postpartum depression, tailored to the client's needs.
A client asks about the risks of long-term oral contraceptive use. Which of the following would the nurse include in the response?
- A. Long-term use eliminates the risk of ovarian cancer.
- B. Long-term use may increase the risk of blood clots.
- C. Long-term use causes permanent infertility.
- D. Long-term use leads to significant weight loss.
Correct Answer: B
Rationale: Long-term use of oral contraceptives may increase the risk of blood clots, especially in smokers or those with other risk factors. It reduces ovarian cancer risk, does not cause permanent infertility, and weight changes vary.
A nurse is teaching a client about the use of condoms for contraception. Which of the following statements by the client indicates understanding of the teaching?
- A. Condoms must be stored in a hot, humid environment.
- B. Condoms can be reused if washed thoroughly.
- C. Condoms provide some protection against STIs.
- D. Condoms are 100% effective in preventing pregnancy.
Correct Answer: C
Rationale: Condoms provide some protection against sexually transmitted infections, which is a key benefit. They should be stored in a cool, dry place, cannot be reused, and are not 100% effective in preventing pregnancy.
A nurse is discussing preterm labor in a prenatal class. After class, a client and her partner ask the nurse to identify again the nursing strategies to prevent preterm labor. The clients need further instruction when they state which of the following?
- A. "I need to stay hydrated all the time."
- B. "I need to avoid any infections."
- C. "I should include frequent rest breaks if we travel."
- D. "Changing to filter cigarettes is helpful."
Correct Answer: D
Rationale: Smoking, even with filter cigarettes, is harmful and should be avoided.