Nokea
The nurse has completed instructions on ways to improve the client’s symptoms related to her rectocele. Which statement by the client indicates a need for further education?
- A. Weight loss will decrease pressure on the pelvic floor.
- B. Increasing fiber and water in my diet will help prevent constipation.
- C. Heavy lifting will not affect my rectocele.
- D. Kegel exercises will help with pelvic floor strength.
Correct Answer: C
Rationale: The correct answer is C because heavy lifting can worsen rectocele symptoms by putting strain on the pelvic floor muscles. A is correct because weight loss reduces pressure. B is correct because fiber and water prevent constipation. D is correct because Kegel exercises strengthen the pelvic floor.
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Which infant is most likely to express Rh incompatibility?
- A. Infant of an Rh-negative mother and a father who is Rh positive and homozygous for the Rh factor.
- B. Infant who is Rh negative and a mother who is Rh negative.
- C. Infant of an Rh-negative mother and a father who is Rh positive and heterozygous for the Rh factor.
- D. Infant who is Rh positive and a mother who is Rh positive.
Correct Answer: A
Rationale: Rationale:
1. Rh incompatibility occurs when the mother is Rh-negative and the father is Rh-positive.
2. If the father is homozygous for Rh factor (AA), all offspring will be Rh-positive.
3. The Rh-positive offspring from an Rh-negative mother can lead to Rh incompatibility.
4. Therefore, the infant of an Rh-negative mother and a father who is Rh positive and homozygous for the Rh factor is most likely to express Rh incompatibility.
Summary:
- Choice B is incorrect because both mother and infant are Rh-negative.
- Choice C is incorrect because the father being heterozygous for the Rh factor would not result in all offspring being Rh-positive.
- Choice D is incorrect as both mother and infant are Rh-positive, so there is no risk of Rh incompatibility.
Phototherapy is instituted for an infant. What is the most appropriate nursing action for the infant having phototherapy?
- A. Cover the infant's head with a hat.
- B. Dress the infant lightly in a T-shirt.
- C. Keep the infant's eyes covered.
- D. Reposition the infant at least every 4 to 8 hours.
Correct Answer: C
Rationale: The correct answer is C: Keep the infant's eyes covered. This is important during phototherapy to protect the infant's eyes from potential damage due to exposure to light. Direct light can harm the infant's developing eyes, so covering them is crucial.
Choice A: Cover the infant's head with a hat - This is not necessary for phototherapy as the focus should be on protecting the eyes, not the head.
Choice B: Dress the infant lightly in a T-shirt - While dressing the infant lightly is recommended, it is not as critical as protecting the eyes.
Choice D: Reposition the infant at least every 4 to 8 hours - Repositioning is important for preventing pressure ulcers but is not directly related to the safety of the eyes during phototherapy.
What nursing action will the nurse implement after feeding an infant with hydrocephalus?
- A. Position the infant sitting upright in an infant seat
- B. Place the infant over the shoulder to burp
- C. Leave the infant in a side-lying position
- D. Stimulate the infant by rubbing its feet
Correct Answer: C
Rationale: The correct answer is C: Leave the infant in a side-lying position. This is important for infants with hydrocephalus as it helps prevent aspiration and reflux. Placing the infant in an upright position (Choice A) may increase the risk of regurgitation and aspiration. Burping (Choice B) is important after feeding but may not specifically address the needs of an infant with hydrocephalus. Stimulating the infant by rubbing its feet (Choice D) is unrelated to the specific care needed for an infant with hydrocephalus.
Reduction in congenital rubella is best accomplished by:
- A. Avoiding contact with young children when infections are prevalent
- B. Taking prophylactic antibiotics during the second half of pregnancy
- C. Testing the rubella titer at the first prenatal visit to determine immunity
- D. Immunizing susceptible women at least 28 days before they become pregnant
Correct Answer: D
Rationale: The correct answer is D because immunizing susceptible women at least 28 days before they become pregnant ensures protection against rubella during pregnancy, reducing the risk of congenital rubella syndrome in the fetus. This timing allows for the development of immunity before conception.
Avoiding contact with young children (A) does not directly prevent rubella transmission to pregnant women. Taking prophylactic antibiotics during pregnancy (B) is not recommended for rubella prevention. Testing rubella titer at the first prenatal visit (C) only assesses current immunity status but does not actively prevent congenital rubella.
The nurse is reviewing the chart of a client who is complaining of heavy bleeding with her menstrual cycles. The nurse is aware that which of the following is a possible cause?
- A. Uterine fibroids
- B. Excessive exercise
- C. Normal finding in pregnancy
- D. Diet high in fat
Correct Answer: A
Rationale: The correct answer is A: Uterine fibroids. Uterine fibroids are noncancerous growths in the uterus that can lead to heavy menstrual bleeding. The nurse should consider this as a possible cause based on the client's symptoms.
Incorrect Choices:
B: Excessive exercise - While excessive exercise can sometimes affect menstrual cycles, it is not a common cause of heavy bleeding.
C: Normal finding in pregnancy - Heavy bleeding during menstrual cycles is not a normal finding in pregnancy.
D: Diet high in fat - While diet can impact overall health, a diet high in fat is not a direct cause of heavy menstrual bleeding.