Nokea
The nurse is caring for a client, 37 weeks' gestation, who was just told that she is group B strep + (positive). The client states, 'How could that happen? I only have sex with my husband. Will my baby be OK?' Based on this information, which of the following should the nurse communicate to the client?
- A. The client's partner must have acquired the bacteria during a sexual encounter.
- B. The bacteria do not injure babies, but they could cause the client to have a bad sore throat.
- C. The client is high risk for developing pelvic inflammatory disease from the bacteria.
- D. Antibiotics will be administered during labor to prevent vertical transmission of the bacteria.
Correct Answer: D
Rationale: Group B strep is a common bacteria that can be present in the vaginal or rectal area and is not sexually transmitted. Antibiotics during labor are given to prevent the baby from contracting the bacteria during delivery.
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When caring for a woman whom a nurse suspects is being abused by her partner, the nurse should do which of the following?
- A. Ask the client directly about how she sustained her injuries.
- B. Counsel the client on how her behavior probably provoked the attack.
- C. Inform the client that the police must arrest her partner.
- D. Give the client a pamphlet with the names of matrimonial attorneys.
Correct Answer: A
Rationale: Directly asking about injuries helps assess the situation and provide appropriate support and resources.
A postpartum client, who delivered her baby vaginally 2 hours earlier, just voided 100 mL in the bathroom. After returning to bed, the nurse makes the following assessment: fundus 4 cm above the umbilicus and deviated to the right with moderate lochia rubra. Which of the following nursing diagnoses is appropriate at this time?
- A. Impaired skin integrity.
- B. Fluid volume deficit.
- C. Impaired urinary elimination.
- D. Toileting self-care deficit.
Correct Answer: C
Rationale: A deviated fundus and moderate lochia rubra suggest urinary retention, which can impede uterine involution.
A woman is admitted to the labor and delivery unit with active tuberculosis. She has not been under a physician's care and is not on medication. Which of the following actions should the nursery nurse perform when the neonate is delivered?
- A. Isolate the baby from the other babies in a special care nursery.
- B. Keep the baby in the regular care nursery but separated from the mother.
- C. Isolate the baby with the mother in the mother's room.
- D. Obtain an order from the doctor for antituberculosis medications for the baby.
Correct Answer: A
Rationale: The baby should be isolated to prevent the spread of tuberculosis to other neonates. The mother should also be treated, but the immediate concern is preventing transmission to others.
A nurse is reading a research study that states, 'There is a strong negative correlation between the independent and dependent variables (r = --0.85).' The nurse interprets the statement as which of the following?
- A. The dependent variable caused a change in the independent variable.
- B. The independent and dependent variables are significantly different.
- C. As values of the independent variable go up, values of the dependent variable go down.
- D. When the confidence interval is computed, the negative value will change to positive.
Correct Answer: C
Rationale: A negative correlation means that as one variable increases, the other decreases. The strength of the correlation is indicated by the absolute value of r.
The umbilical cord is being clamped by the obstetrician. Which of the following physiological changes is taking place at this time?
- A. The baby’s blood bypasses its pulmonary system.
- B. The baby’s oxygen level begins to drop.
- C. Bacteria begin to invade the baby’s bowel.
- D. Bilirubin rises in the baby’s bloodstream.
Correct Answer: A
Rationale: Clamping the umbilical cord initiates the transition from fetal to neonatal circulation, allowing blood to bypass the pulmonary system as the lungs take over oxygen exchange.