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The nurse is planning care for a 4-year-old girl who is diagnosed with a developmental disability. What should be the primary focus of treatment for this child?
- A. Teach her social skills.
- B. Assist in preventing further disability.
- C. Ensure her participation in group activities.
- D. Help her achieve her maximum potential.
Correct Answer: D
Rationale: The primary focus of treatment for a child diagnosed with a developmental disability should be to help them achieve their maximum potential. This approach aims to optimize the child's physical, emotional, cognitive, and social abilities, focusing on enhancing their overall well-being and quality of life. By supporting the child in reaching their highest level of functioning, caregivers can promote independence, self-esteem, and personal growth, which are essential components of holistic care for individuals with developmental disabilities.
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When can a woman who thinks she may be pregnant use a home pregnancy test to diagnose pregnancy?
- A. A home pregnancy test can be used right after your first missed period.
- B. These tests are most accurate after you have missed your second period.
- C. Home pregnancy tests often give false positives and should not be trusted.
- D. The test can provide accurate information when used right after ovulation.
Correct Answer: A
Rationale: The correct answer is A. Home pregnancy tests detect hCG, a hormone produced during pregnancy, and are most accurate after the first missed period when hCG levels are higher. Testing too early may result in a false negative. Waiting until after the first missed period increases the reliability of the test results.
Upon arrival in the nursery, a newborn infant is breathing satisfactorily but appears dusky. What action should the LPN/LVN take first?
- A. Notify the healthcare provider immediately.
- B. Suction the infant's nares, then the oral cavity.
- C. Check the infant's oxygen saturation rate.
- D. Position the infant on the right side.
Correct Answer: C
Rationale: The priority action in this scenario is to check the infant's oxygen saturation rate. This will provide crucial information on the infant's oxygen levels and the need for immediate oxygen therapy. Assessing oxygen saturation is essential in determining the severity of hypoxia and guiding further interventions to ensure adequate oxygenation.
A client who delivered vaginally 2 days ago states that she wants to resume using her diaphragm for birth control. What information should you share with her?
- A. The most effective form of contraception is a diaphragm.
- B. The diaphragm must be refitted after childbirth.
- C. Vaseline lubricant can be used when inserting the diaphragm.
- D. The diaphragm should be inserted 2 to 4 hours before intercourse.
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The healthcare provider is preparing to administer magnesium sulfate to a laboring client whose blood pressure has increased from 110/60 mmHg to 140/90 mmHg. Which action is the highest priority?
- A. Provide a quiet environment with subdued lighting.
- B. Have calcium gluconate immediately available.
- C. Assess deep tendon reflexes (DTRs) every 4 hours.
- D. Insert a Foley catheter with a urimeter to monitor hourly output.
Correct Answer: B
Rationale: Having calcium gluconate readily available is crucial when administering magnesium sulfate, as it serves as the antidote in case of magnesium toxicity. Magnesium sulfate can lead to respiratory depression and cardiac arrest in cases of overdose or toxicity, making the prompt availability of calcium gluconate essential for immediate administration to counteract these effects.
A 34-week primigravida woman with preeclampsia is receiving Lactated Ringer's 500ml with magnesium sulfate 20 grams at the rate of 3g/hr. How many ml/hr should the nurse program the infusion pump?
- A. 75ml/hr
- B. 100ml/hr
- C. 50ml/hr
- D. 25ml/hr
Correct Answer: A
Rationale: To calculate the infusion rate, divide the total quantity to be infused (500ml) by the total time (1 hour) which equals 500ml/hr. Since the magnesium sulfate is being given at 3g/hr, and 1g of magnesium sulfate is in 5ml of solution, the rate will be 3g/hr x 5ml/g = 15ml/hr. Therefore, the total infusion rate should be 500ml/hr + 15ml/hr = 515ml/hr. Hence, the nurse should program the infusion pump to deliver 75ml/hr (515ml/hr total - 500ml/hr Lactated Ringer's rate).