Nokea
The nurse is caring for a one-year-old child following surgical correction of hypospadias. Which nursing action has the highest priority?
- A. Monitor urinary output
- B. Auscultate bowel sounds
- C. Observe appearance of stool
- D. Record percent of diet consumed
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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The healthcare provider prescribes magnesium sulfate 6 grams intravenously (IV) to be infused over 20 minutes for a client with preterm labor. The IV bag contains magnesium sulfate 20 grams in dextrose 5% in water 500 mL. How many mL/hour should the nurse set the infusion pump?
- A. 150 mL/hour
- B. 250 mL/hour
- C. 50 mL/hour
- D. 275 mL/hour
Correct Answer: A
Rationale: To calculate the infusion rate, first, determine the total volume to be infused (6 grams of magnesium sulfate) over a specific time frame (20 minutes). Then, calculate the concentration of magnesium sulfate in the IV bag to determine the mL/hour rate. In this case, with 20 grams of magnesium sulfate in 500 mL of solution, there are 4 grams of magnesium sulfate per 100 mL. Since 6 grams are required, the nurse should set the pump to deliver 150 mL/hour to infuse the prescribed dose over 20 minutes. This calculation ensures the correct dose is delivered within the specified time frame.
When preparing a class on newborn care for expectant parents, what content should be taught concerning the newborn infant born at term gestation?
- A. Milia are white marks caused by sebaceous glands and typically resolve within 2 to 4 weeks.
- B. Meconium is the first stool and is typically dark green or black in color.
- C. Vernix caseosa is a white, cheesy substance mainly found in skin folds, providing a protective layer.
- D. Pseudostrabismus in newborns usually self-resolves without the need for intervention.
Correct Answer: C
Rationale: Vernix caseosa is a white, cheesy substance that acts as a protective barrier on the skin of newborns, particularly present in skin folds. It helps to prevent dehydration and protect the delicate skin of the newborn from the amniotic fluid in utero. Educating expectant parents about the presence and function of vernix caseosa can help them understand the importance of its preservation during the immediate postnatal period.
A client at 32-weeks gestation is diagnosed with preeclampsia. Which assessment finding is most indicative of an impending convulsion?
- A. 3+ deep tendon reflexes and hyperreflexia.
- B. Periorbital edema, flashing lights, and aura.
- C. Epigastric pain in the third trimester.
- D. Recent decreased urinary output.
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The healthcare provider is preparing to suture a 10-year-old with a lacerated forehead. Both parents and the 12-year-old sibling are at the child's bedside. Which instruction best supports the family?
- A. While waiting for the healthcare provider, only one family member may stay with the child.
- B. All family members should leave while the healthcare provider sutures the child's forehead.
- C. It is best if the sibling goes to the waiting room until the suturing is completed.
- D. Please decide among yourselves who will stay when the healthcare provider begins suturing.
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A new mother who is breastfeeding her 4-week-old infant and has type 1 diabetes reports that her insulin needs have decreased since the birth of her child. Which action should the nurse implement?
- A. Inform her that a decreased need for insulin occurs while breastfeeding.
- B. Counsel her to increase her caloric intake.
- C. Advise the client to breastfeed more frequently.
- D. Schedule an appointment for the client with the diabetic nurse educator.
Correct Answer: A
Rationale: During breastfeeding, insulin needs often decrease due to the metabolic demands of milk production. Therefore, the nurse should inform the client that this decrease in insulin requirements is a normal response to breastfeeding. It is essential for healthcare providers to educate clients about this physiological change to prevent unnecessary concerns or adjustments to insulin therapy.