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The nurse is caring for a client with severe preeclampsia. What is the priority nursing action?
- A. Administer antihypertensive medication.
- B. Assess for signs of impending eclampsia.
- C. Monitor urine protein levels.
- D. Encourage ambulation.
Correct Answer: B
Rationale: Assessing for signs of impending eclampsia, such as severe headache or visual changes, is critical to prevent seizures.
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What are the modes of heat loss in babies? SATA
- A. Radiation
- B. Conduction
- C. Convection
- D. Perspiration (baby's don't perspir
Correct Answer: A
Rationale: A. Radiation: Heat loss through radiation occurs when the baby is near a cold surface or in a drafty room, causing heat to transfer from the baby's body to the surrounding environment.
The nurse is preparing a client for a postpartum tubal ligation. What is the priority preoperative nursing action?
- A. Insert an indwelling catheter.
- B. Verify signed informed consent.
- C. Administer prescribed antibiotics.
- D. Check for maternal vital signs.
Correct Answer: B
Rationale: Verifying informed consent is essential before proceeding with any surgical procedure.
The nurse is teaching a client with a midline episiotomy about perineal care after vaginal birth. Which statement from the client indicates she
- B. I will use the perineal bottle without touching perineum each time going to the bathroom
- C. I will gently pat perineal dry rather than wipe
- D. I will only use the perineal bottle after bowel movements
Correct Answer: C
Rationale: This statement indicates a correct understanding of perineal care after a midline episiotomy. After vaginal birth, it is important to avoid wiping the perineal area to prevent irritation and infection. Instead, gently patting the area dry is recommended to promote healing and prevent discomfort. This approach helps to minimize trauma to the sensitive tissues of the perineum and reduces the risk of introducing bacteria from wiping.
According to the ACC/AHA guidelines, what factors are considered to assess a person's 10-year risk of developing a first cardiovascular event?
- A. age, sex, race, blood pressure, and smoking status
- B. age, sex, race, total cholesterol, HDL cholesterol, systolic blood pressure, blood pressure–lowering medication use, diabetes status, and smoking status
- C. blood pressure, cholesterol levels, diabetes status, and weight
- D. age, sex, race, and weight
Correct Answer: B
Rationale:
A nurse is assessing a newborn upon admission to the nursery. Which of the following should the nurse expect?
- A. Bulging Fontanels
- B. Nasal Flaring
- C. Length from head to heel of 40 cm (15.7 in)
- D. Chest circumference 2 cm (0.8 in) smaller than the head circumference
Correct Answer: D
Rationale: When a nurse is assessing a newborn upon admission to the nursery, it is expected that the chest circumference will be smaller than the head circumference. This is a normal finding in a newborn, where the head circumference is slightly larger than the chest circumference due to the proportionate sizes of the newborn's head and chest. This difference helps accommodate the vital organs within the chest cavity while allowing for the growth and development of the brain. Therefore, a chest circumference that is 2 cm smaller than the head circumference is a typical and expected finding in a newborn assessment.