Nokea
The nurse is teaching a group of prenatal clients about the effects of cigarette smoke on fetal development. Which characteristic is associated with babies born to mothers who smoked during pregnancy?
- A. Low birth weight
- B. Large for gestational age
- C. Preterm birth,but appropriate size for gestation
- D. Growth retardation in weight and length
Correct Answer: A
Rationale: Smoking during pregnancy restricts placental blood flow leading to low birth weight. Babies are not typically large and while preterm birth or growth retardation may occur low birth weight is the most consistent finding.
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What information should the nurse give a new mother regarding the introduction of solid foods for her infant?
- A. Solid foods should not be given until the extrusion reflex disappears at 8-10 months of age.
- B. Solid foods should be introduced one at a time, with 4- to 7-day intervals.
- C. Solid foods can be mixed in a bottle or infant feeder, to make feeding easier.
- D. Solid foods should begin with fruits and vegetables.
Correct Answer: B
Rationale: Introducing solid foods one at a time with 4-7 day intervals allows identification of allergies. The extrusion reflex fades by 4-6 months, and mixing in bottles or starting with fruits is not recommended.
The nurse has performed nutritional teaching on a client with gout who is placed on a low-purine diet. Which selection by the client would indicate that teaching has been ineffective?
- A. Boiled cabbage
- B. Apple
- C. Peach cobbler
- D. Spinach
Correct Answer: D
Rationale: Spinach is high in purines, which exacerbate gout. Selecting spinach indicates ineffective teaching. Cabbage (A), apple (B), and peach cobbler (C) are low-purine and appropriate.
The charge nurse is making assignments for the day. After accepting the assignment to care for a client with leukemia, the nurse tells the charge nurse that her child has chickenpox. Which initial action should the charge nurse take?
- A. Change the nurse's assignment to another client.
- B. Explain to the nurse that there is no risk to the client.
- C. Ask the nurse if the chickenpox have crusted.
- D. Ask the nurse if she has ever had the chickenpox.
Correct Answer: D
Rationale: The charge nurse should first ask if the nurse has had chickenpox or been vaccinated, as immunity prevents transmission to the immunocompromised leukemia client. If non-immune, the assignment should be changed. Asking about crusting or explaining no risk is incorrect, as varicella is contagious until lesions crust.
The client at 35 weeks gestation is admitted with a diagnosis of vasa previa. The nurse should monitor for which complication?
- A. Fetal bleeding
- B. Maternal hemorrhage
- C. Preterm labor
- D. Fetal macrosomia
Correct Answer: A
Rationale: Vasa previa involves fetal blood vessels crossing the cervical os risking rupture and fetal bleeding during labor or membrane rupture. Maternal hemorrhage preterm labor and macrosomia are less directly related.
Which information should be given to the client using a TENS unit?
- A. Electrocution may occur if you use water with this unit.'
- B. Skin irritation may occur with prolonged use of the unit.'
- C. The unit can be placed anywhere on the body without fear of adverse reactions.'
- D. A cream or lotion should be applied to the skin before applying the unit.'
Correct Answer: B
Rationale: Prolonged use of a TENS unit can cause skin irritation due to electrode adhesion or electrical stimulation. Electrocution is not a risk with battery-operated units, placement requires specific guidance, and lotions may interfere with electrode contact.