Nokea
The nurse is caring for a child brought to the emergency department by a babysitter. The child needs an emergency appendectomy and the parents cannot be contacted. What would be the nurse's best response to this situation?
- A. Have the babysitter sign the consent form even if she does not have signed papers to do so.
- B. Have the primary care physician for the child sign the consent form.
- C. Document failed attempts to obtain consent to allow emergency care.
- D. Delay medical care until the child's next of kin can be contacted.
Correct Answer: C
Rationale: Health care providers can provide emergency treatment to a child without consent if they have made reasonable attempts to contact the child's parent or legal guardian.
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The nurse assures the breastfeeding mother that she will know that her infant is getting an adequate supply of breast milk if the infant gains weight and:
- A. Rarely sucks on a pacifier.
- B. Ha several hard stools daily
- C. Voids 6 or more times a day
- D. Awakens to feed every 4 hours
Correct Answer: C
Rationale: Frequent voiding indicates adequate intake.
The nurse is educating a client with gestational diabetes about blood sugar monitoring. What statement indicates understanding?
- A. I will check my blood sugar once a week.
- B. I should avoid all carbohydrates.
- C. I will monitor my blood sugar four times a day as prescribed.
- D. I can skip insulin on days I feel well.
Correct Answer: C
Rationale: Frequent monitoring of blood sugar is essential for managing gestational diabetes effectively.
A neonate is being discharged home with a fiber-optic blanket for treatment of physiologic jaundice. What is important for the nurse to include in the discharge instructions?
- A. Cover the infant's eyes during the treatment.
- B. Reduce the daily number of formula feedings.
- C. Encourage frequent feeding to increase intake.
- D. Expect a constipated stool until jaundice clears.
Correct Answer: C
Rationale: Frequent feeding aids in bilirubin excretion.
A nurse on the labor and delivery unit is caring for a client who is having a difficult, prolonged labor with severe backache. Which of the following contributing causes should the nurse identify
- A. Fetal attitude is in general flexion.
- B. Fetal lie is longitudinal.
- C. Maternal pelvis is gynecoid.
- D. Fetal position is persistent occiput posterior.
Correct Answer: D
Rationale: In a labor where the fetal position is persistent occiput posterior, the baby is positioned face up, which can lead to a longer and more difficult labor. In this position, the baby's head is pressing against the mother's spine, causing severe backache for the mother. This malposition can slow down the progress of labor, making it more prolonged and challenging. It can also increase the likelihood of complications such as increased risk of instrumental delivery or cesarean section. Therefore, identifying the fetal position as persistent occiput posterior as a contributing cause to the difficult, prolonged labor with severe backache is crucial for effective management and intervention.
A nurse is assessing a newborn following a forceps assisted birth. Which of the following clinical manifestations should the nurse identify as a complication of the birth method?
- A. Hypoglycemia
- B. Polycythemia
- C. Facial Palsy
- D. Bronchopulmonary dysplasia
Correct Answer: C
Rationale: Facial Palsy is a complication that may occur following a forceps-assisted birth. Forceps delivery carries the risk of exerting pressure on the infant's facial nerves, leading to temporary facial weakness or paralysis. This condition is known as facial palsy. It typically resolves on its own without long-term consequences, but careful monitoring and follow-up are necessary.