Nokea
The nurse is preparing a young couple and their 24-hour-old infant for discharge from the hospital. In conducting discharge teaching, which intervention is most important for the nurse to implement?
- A. Request a return demonstration of a diaper change
- B. Evaluate infant feeding techniques prior to discharge
- C. Provide the results of the infant's hearing test to the parents.
- D. Ensure that they have the pediatric clinic's phone number
Correct Answer: B
Rationale: Proper feeding techniques are critical for the infant's nutrition and growth, making evaluation of these skills the priority before discharge.
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A client at 40-weeks gestation presents to the obstetrical floor and indicates that the amniotic membranes ruptured spontaneously at home. She is in active labor, and feels the need to bear down and push. Which information is most important for the nurse to obtain?
- A. Estimated amount of fluid.
- B. Color and consistency of fluid.
- C. Time the membranes ruptured
- D. Any odor noted when membranes ruptured
Correct Answer: C
Rationale: The time of membrane rupture is critical to assess the risk of infection, which increases with prolonged rupture, especially in active labor.
The nurse is preparing to administer magnesium sulfate to a laboring client whose blood pressure has increased from 110/60 mmHg to 140/90 mmHg Which nursing protocol has the highest priority?
- A. Insert a Foley catheter with a urimeter to monitor hourly output
- B. Have calcium gluconate immediately available
- C. Provide a quiet environment with subdued lighting.
- D. Assess deep tendon reflexes (DTRS) every 4 hours.
Correct Answer: B
Rationale: Magnesium sulfate toxicity can cause neuromuscular blockade, making calcium gluconate, the antidote, critical to have immediately available in case of toxicity signs like loss of deep tendon reflexes.
A client who delivered vaginally 2 days ago states that she wants to resume using her diaphragm for birth control. What information should the nurse share with her?
- A. The diaphragm must be refitted after childbirth
- B. The most effective form of contraception is a diaphragm
- C. The diaphragm should be inserted 2 to 4 hours before intercourse.
- D. Vaseline lubricant can be used when inserting the diaphragm
Correct Answer: A
Rationale: Childbirth can alter vaginal and cervical anatomy, requiring the diaphragm to be refitted for effective contraception.
During the newborn admission assessment, the nurse palpates the newborn's scrotum and does not feel the testicles. Which assessment technique should the nurse perform next to verify the absence of testes?
- A. Use a fingertip to palpate the inguinal canal for a weakening or indentation
- B. Measure the size of the scrotal sac for length and width.
- C. Perform transillumination of the scrotal sac to visualize shadows of the testes
- D. Observe the urethral opening on the surface of the penis when the newborn voids
Correct Answer: A
Rationale: Palpating the inguinal canal is the next step to check for undescended testes, which may be located in the inguinal area.
A multiparous client with active herpes lesions is admitted to the unit with spontaneous rupture of membranes. Which action should the nurse take?
- A. Prepare for a cesarean section
- B. Cover the lesion with a dressing
- C. Obtain blood cultures
- D. Administer penicillin.
Correct Answer: A
Rationale: Active herpes lesions pose a risk of neonatal herpes transmission during vaginal delivery. Preparing for a cesarean section is the priority to minimize this risk.