Nokea
The nurse discovers that an African couple from Kenya has not named their 48-hour-old,full-term newborn and the infant and mother are being discharged to home. Which action should the nurse take in response to this information?
- A. Ask the parents to choose a name before discharge.
- B. Encourage other appropriate attachment behaviors.
- C. Document the discharge and that the baby is unnamed.
- D. Delay discharge until parental attachment is addressed.
Correct Answer: C
Rationale: In Kenyan culture naming may occur on the third day with celebration. Documenting the discharge and unnamed status is appropriate; naming isn’t required for attachment.
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A primigravida is in second stage of labour for the past two hours. Fetal head is at +1 station. Inspite of effective uterine contractions,mother is unable to push as she is exhausted. What will be the next step in her management:
- A. Wait for another one hour.
- B. Give sedation to the mother.
- C. Shift her for emergency section.
- D. Instrumental delivery.
- E. Call the anaesthetist for regional anaesthesia.
Correct Answer: D
Rationale: Instrumental delivery (e.g. forceps or vacuum) is indicated for prolonged second stage due to maternal exhaustion provided the fetal head is engaged (+1 station). Cesarean section is considered if instrumental delivery is not feasible.
Because the burned child is confined to bed, the nurse assesses for footdrop. Which nursing action best prevents the development of footdrop?
- A. Apply braces to the feet and ankles.
- B. Keep the child in the side-lying position.
- C. Keep sheets tucked in at the foot of the bed.
- D. Rest the child's feet against a footboard.
Correct Answer: D
Rationale: Resting the child's feet against a footboard maintains the feet in a neutral position, preventing plantar flexion and footdrop during prolonged bed rest.
While supervising the LPN,the RN determines that the LPN needs additional instruction in newborn care. Which action by the LPN prompted the nurse’s conclusion?
- A. Assessed the newborn’s heart rate apically
- B. Covered the newborn’s head with a stocking cap
- C. Checked the newborn’s temperature rectally
- D. Positioned the newborn supine while sleeping
Correct Answer: C
Rationale: Rectal temperature checks risk mucosal irritation or perforation. Apical HR assessment stocking caps and supine positioning (to reduce SIDS risk) are correct practices.
Which statement by the nurse is most therapeutic in addressing the teen's behavior?
- A. There's nothing to be scared of. This won't hurt.
- B. The stitches are strong. They won't come out.
- C. I know you're scared, but you must be brave.
- D. Let's do this later, when you're better prepared.
Correct Answer: C
Rationale: Acknowledging the teen's fear and encouraging bravery validates their emotions while gently motivating them to proceed with ambulation, fostering trust and cooperation.
When caring for a child with measles, which precaution is most appropriate for the nurse to implement?
- A. Standard precautions
- B. Droplet precautions
- C. Contact precautions
- D. Airborne precautions
Correct Answer: D
Rationale: Measles is highly contagious and spreads via airborne transmission, requiring airborne precautions, including a negative-pressure room and N95 respirator use.