Nokea
The nurse is caring for a primigravida client who delivered vaginally 48-hours ago. The client's laboratory results are: hemoglobin 12.5 g/dL (125 g/L), hematocrit 34% (0.34 volume fraction), hepatitis B surface antigen negative, rubella non-immune, group B Streptococcus positive. Which prescription should the nurse prepare to administer?
- A. Hepatitis B immunoglobulin.
- B. Rubella vaccination.
- C. Blood transfusion.
- D. Penicillin G potassium.
Correct Answer: B
Rationale: The client's rubella non-immune status requires postpartum vaccination to prevent future congenital defects. Normal hemoglobin/hematocrit, negative hepatitis B, and post-delivery GBS status do not warrant other interventions.
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The nurse is caring for an infant admitted with dehydration, irritability, signs of extreme hunger, and a palpable olive-like mass in the upper right abdominal quadrant. When feeding the infant, the nurse should monitor for which development?
- A. Arched back.
- B. Coffee-ground emesis.
- C. Projectile vomiting.
- D. Frequent pauses.
Correct Answer: C
Rationale: Projectile vomiting is characteristic of pyloric stenosis, indicated by the olive-like mass, hunger, and dehydration.
Nurses' Notes
Orders
The client is a 4-month-old female with a history of gastroesophageal reflux (GERD). Client had fundoplication surgery and will be hospitalized for several days of recovery.
Which other assessment data would the nurse want to collect before implementing pain management strategies? Select all that apply.
- A. Blood type
- B. Parents religious affiliation
- C. Blood pressure
- D. Level of consciousness
- E. Hearing acuity
- F. Heart rate
- G. Deep tendon reflexes
Correct Answer: C,D,F
Rationale: Blood pressure, level of consciousness, and heart rate assess pain intensity and guide safe pain management. Blood type, religion, hearing, and reflexes are not directly relevant.
The nurse is giving instructions to the mother of a 10-year-old boy who is newly diagnosed with type 1 diabetes mellitus (DM). When attempting to teach the mother how to administer subcutaneous insulin injections to the child, the mother tells the nurse that she is afraid of needles and cannot perform the procedure. Which intervention should the nurse implement?
- A. Determine if the child can administer the insulin.
- B. Ask if the father can help with the injections.
- C. Assess the mother's parenting skills.
- D. Encourage the mother to handle the needles.
Correct Answer: D
Rationale: Gradual exposure to needles through practice builds the mother's confidence, ensuring effective insulin administration for diabetes management.
Which drink choice on a hot day indicates to the nurse that an adolescent with sickle cell anemia understands dietary considerations related to the disease?
- A. Diet cola.
- B. Ice tea.
- C. Lemonade.
- D. Milkshake.
Correct Answer: C
Rationale: Lemonade, a hydrating, caffeine-free drink, prevents dehydration, reducing sickling risk in sickle cell anemia.
The nurse is preparing to administer oxytocin IV to a client after the delivery of her infant. Which outcome should the nurse expect from the administration of oxytocin?
- A. Return of the uterus to prepregnancy size.
- B. Expulsion of the placenta.
- C. Activation of the let down reflex.
- D. Stimulation of uterine contractions.
Correct Answer: D
Rationale: Oxytocin stimulates uterine contractions to reduce postpartum bleeding by compressing blood vessels.