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The nurse has been assigned a client who delivered a 6-lb, 12-oz baby boy vaginally 40 minutes ago. The initial assessment of greatest importance for this client would be:
- A. Length of her labor
- B. Type of episiotomy
- C. Amount of IV fluid to be infused
- D. Character of the fundus
Correct Answer: D
Rationale: The length of labor has little bearing on the fourth stage of labor. The type of labor and delivery is significant. The type of episiotomy will affect the client's comfort level. However, the nurse's assessment and implementations center on prevention of hemorrhage during the fourth stage of labor. The amount of bleeding from the episiotomy or hematoma formation is of higher priority than the type of episiotomy. The amount of IV fluid to be infused is a nursing function to be attended to; however, it is lower in priority than determining if hemorrhaging is occurring. Character of the fundus would be the priority nursing assessment because changes in uterine tone may identify possible postpartum hemorrhage.
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A 1-year-old child is to receive an IM injection ordered by his pediatrician. He has fallen asleep in his mother's arms when the nurse approaches. Which approach is most appropriate at this time?
- A. Give the injection in the vastus lateralis site before the child awakens.
- B. Awaken the child first and give the injection in the ventrogluteal site.
- C. Awaken the child first and give the injection in the dorsogluteal site.
- D. Ask the mother to place the child on the examination table and leave the room, and then give the injection in an appropriate site.
Correct Answer: B
Rationale: If awakened first, the child will know that nothing painful will be done without the child being alerted. The ventrogluteal site is a safe site for children because it is a large muscle free of major nerves and blood vessels. The dorsogluteal site is not recommended in children who have not been walking for at least 1 year because the muscle is not fully developed. The parent will be able to offer support and comfort during and after the injection.
A home health nurse has several elderly clients in her case load. Which of the following clients ~(is most likely to be a victim of elder abuse?
- A. A 76-year-old female with Alzheimer's dementia
- B. A 70-year-old male with diabetes mellitus
- C. A 64-year-old female with a hip replacement
- D. A 72-year-old male with Parkinson's disease
Correct Answer: A
Rationale: Elderly clients with Alzheimer's dementia are at highest risk for abuse due to cognitive impairment, dependency, and potential caregiver stress. The other conditions pose less risk.
A 45-year-old male client experiences a sense of depression because he has not yet achieved his life's goals. His career has not been satisfying. He is still looking for the right job. His wife spends too much money, and his children seem to ignore him while being very selfish. He is tired of all of their attitudes and is considering buying a red Corvette convertible. While obtaining these data concerning the client's feelings about his life, the nurse is able to determine he is experiencing what psychological crisis according to Erikson's stages?
- A. Identity versus role confusion
- B. Integrity versus despair
- C. Intimacy versus isolation
- D. Generativity versus self-absorption
Correct Answer: D
Rationale: Identity versus role confusion is experienced by adolescents making the transition from childhood to adulthood as they attempt to develop a sense of identity. Integrity versus despair is experienced by the elderly as they reflect on their life in an attempt to find meaning. Intimacy versus isolation is experienced by young adults as they establish intimate bonds of love and friendship. Generativity versus self-absorption is experienced by middle-aged adults as they fulfill life goals that involve family, career, and society. The client is experiencing this crisis.
The nurse is caring for a client with a diagnosis of gestational hypertension. Which intervention is most appropriate?
- A. Monitor blood pressure
- B. Administer antihypertensives
- C. Monitor fetal heart tones
- D. All of the above
Correct Answer: D
Rationale: Gestational hypertension requires blood pressure monitoring to assess severity antihypertensives for severe hypertension and fetal heart tone monitoring to ensure fetal well-being. All interventions are appropriate.
A client suspects that she is pregnant. She reports two missed menstrual periods. The first day of her last menstrual period was August 3. Her estimated date of confinement would be:
- A. 7-Nov
- B. 10-Nov
- C. 7-May
- D. 10-May
Correct Answer: D
Rationale: Using Nägele's rule (LMP - 3 months + 7 days + 1 year), August 3 leads to an estimated delivery date of May 10.