Nokea
The nurse is caring for a postpartum client who reports feeling overwhelmed and tearful. What is the nurse's priority intervention?
- A. Administer a sedative as prescribed.
- B. Encourage the client to rest and sleep.
- C. Provide emotional support and reassurance.
- D. Refer the client to a mental health professional.
Correct Answer: C
Rationale: The correct answer is C: Provide emotional support and reassurance. This is the priority intervention because the client is feeling overwhelmed and tearful, indicating a need for immediate emotional support. Administering a sedative (A) may mask the underlying issue and is not addressing the client's emotional needs. Encouraging rest and sleep (B) is important but secondary to addressing the client's emotional state. Referring the client to a mental health professional (D) may be necessary in the long term but is not the immediate priority in this situation. Emotional support and reassurance can help the client feel validated and supported in the moment.
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What can self-awareness with postural adjustments lead to?
- A. tension formation
- B. tension release
- C. suboptimal posture
- D. back pain
Correct Answer: B
Rationale: Self-awareness with postural adjustments can lead to tension release because it allows individuals to identify and correct any muscular imbalances or poor postural habits. By being aware of their body positioning and making necessary adjustments, individuals can reduce muscle tension and promote proper alignment, leading to relaxation and alleviation of tension. This proactive approach helps prevent the buildup of tension in muscles, ultimately promoting overall well-being.
Incorrect Choices:
A: Tension formation - Self-awareness with postural adjustments helps prevent tension formation by addressing imbalances.
C: Suboptimal posture - Self-awareness promotes optimal posture by making adjustments.
D: Back pain - Proper postural adjustments can alleviate back pain, not cause it.
How can a nurse reduce the risk of infection in a newborn in the NICU?
- A. Maintain strict hand hygiene
- B. Limit visitors and monitor closely for signs of infection
- C. Ensure proper sterilization of equipment
- D. Administer prophylactic antibiotics
Correct Answer: B
Rationale: Rationale for Correct Answer (B): Limiting visitors and monitoring closely for signs of infection in a newborn in the NICU is crucial because newborns are highly vulnerable to infections. By restricting visitors, the risk of introducing pathogens is reduced. Close monitoring allows for early detection of any signs of infection, enabling prompt intervention to prevent complications.
Summary of Other Choices:
A: While maintaining strict hand hygiene is important, it alone is not sufficient to reduce the risk of infection in a newborn in the NICU.
C: Proper sterilization of equipment is essential but may not directly address the risk of infection transmission from visitors or other sources.
D: Administering prophylactic antibiotics is not recommended as a routine measure due to the potential for antibiotic resistance and adverse effects in newborns. Monitoring and prevention are preferred over indiscriminate antibiotic use.
The nurse is monitoring a postpartum client. What finding requires immediate action?
- A. Fundus firm and midline.
- B. Lochia rubra with large clots.
- C. Mild perineal discomfort.
- D. Slight swelling of the feet.
Correct Answer: B
Rationale: The correct answer is B because Lochia rubra with large clots may indicate excessive bleeding or a possible postpartum hemorrhage, which requires immediate intervention to prevent complications. A: Fundus firm and midline is a normal finding postpartum. C: Mild perineal discomfort is expected after childbirth. D: Slight swelling of the feet is common due to fluid shifts and does not require immediate action.
The nurse is reviewing a prenatal chart and notes a client with placenta previa. What is the priority nursing consideration?
- A. Encourage vaginal delivery.
- B. Avoid vaginal examinations.
- C. Encourage bed rest at home.
- D. Prepare for immediate induction of labor.
Correct Answer: B
Rationale: The correct answer is B: Avoid vaginal examinations. Placenta previa is a condition where the placenta partially or completely covers the cervix, increasing the risk of bleeding. Vaginal examinations can trigger bleeding by disrupting the placenta. The priority is to minimize the risk of bleeding and prevent complications. Encouraging vaginal delivery (A) is contraindicated due to the risk of hemorrhage. Bed rest at home (C) may be recommended but is not the priority. Immediate induction of labor (D) can be dangerous and is not indicated unless there is an emergency situation.
Which of the following findings would indicate
- A. Reversal of a tubal ligation is easily done, with a an infant who may be considered preterm?
- B. Labia minora are larger than labia majora
- C. After this procedure, I must abstain from inter-
- D. Plantar creases cover two-thirds of foot
Correct Answer: D
Rationale: The correct answer is D because plantar creases covering two-thirds of the foot is a typical finding in Down syndrome. This is known as the Sandal gap sign, which is a characteristic feature of Down syndrome. The other choices are incorrect because: A is not related to any specific medical condition, B describes a normal anatomical variation, and C is incomplete and does not provide enough information to determine its relevance.