Nokea
The nurse correctly advises the client that she is still considered infectious until which time?
- A. She no longer has foul-smelling vaginal discharges.
- B. She no longer experiences discomfort during her menstrual periods.
- C. She has a negative culture after being off antibiotics for at least 7 days.
- D. She has taken the prescribed doses of ceftriaxone (Rocephin) for 1 day.
Correct Answer: C
Rationale: A negative culture after completing antibiotics and being off them for at least 7 days confirms the infection is cleared, ensuring the client is no longer infectious.
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The nurse evaluates that the newborn’s Moro reflex is WNL. Which response by the newborn prompted the nurse’s conclusion?
- A. Straightens extremities and then flexes them in response to a loud noise
- B. Right-side extremity extension when the head is quickly turned right
- C. Turns the head toward the right side when the right cheek is touched
- D. Attempts to walk when the sole of the foot touches a hard surface
Correct Answer: A
Rationale: An intact Moro reflex involves extremity extension then flexion in response to a loud noise. Other options describe tonic neck rooting and stepping reflexes.
The postpartum client (G2P2) asks the nurse for suggestions to help facilitate her 3-year-old’s attachment and acceptance of their newborn. Which action should the nurse suggest?
- A. Provide a doll for the 3-year-old to care for and nurture.
- B. Avoid bringing the 3-year-old to the “scary” hospital.
- C. Plan that dad cares for the 3-year-old and mom cares for the baby.
- D. Encourage the child to be “grown up” and accept the newborn.
Correct Answer: A
Rationale: Providing a doll encourages the 3-year-old to mimic parental care reducing jealousy. Hospital visits shared parental attention and accepting regression promote bonding.
If the child weighs 30 kg, what is the hourly flow rate in milliliters? Use the standard 100 mL/kg/day for the first 10 kg of body weight, 50 mL/kg/day for the next 10 kg of body weight, and 20 mL/kg/day for each kilogram above 20 kg of body weight for daily maintenance.
Correct Answer: 70.83 mL/hour
Rationale: Calculation: First 10 kg = 100 mL/kg/day × 10 = 1000 mL/day; Next 10 kg = 50 mL/kg/day × 10 = 500 mL/day; Last 10 kg = 20 mL/kg/day × 10 = 200 mL/day. Total = 1000 + 500 + 200 = 1700 mL/day. Hourly rate = 1700 ÷ 24 = 70.83 mL/hour. Since no exact option is provided, the closest reasonable answer is assumed as correct based on standard practice.
Which statement by the parents indicates they understand the home care instructions given by the nurse?
- A. We've made arrangements for a homebound teacher.
- B. We'll use ice packs on our child's joints during episodes of inflammation.
- C. We'll serve meals that prevent excess weight gain.
- D. We'll keep our child in bed most of the time.
Correct Answer: C
Rationale: Maintaining a healthy weight reduces stress on inflamed joints in JRA. Serving meals that prevent excess weight gain shows understanding of home care instructions to support joint health.
The nurse is caring for the newborn infant. Which initial measures should the nurse take to maintain the newborn’s axillary body temperature between 97.7°F (36.5°C) and 98.9°F (37.2°C)? Select all that apply.
- A. Carefully dry the infant immediately after birth.
- B. Place the infant skin-to-skin with the mother.
- C. Apply leggings to both of the newborn’s legs.
- D. Cover the infant’s head with a stocking cap.
- E. Place the infant in a bassinette close to the wall.
Correct Answer: A,B,D
Rationale: Drying the newborn prevents heat loss through evaporation. Skin-to-skin contact with the mother assists in maintaining body temperature. A stocking cap conserves heat. Leggings are unnecessary and placing the bassinette near a wall causes radiation heat loss.