Nokea
The nurse is teaching childbirth preparation classes. One woman asks about her rights to develop a birthing plan. Which response made by the nurse would be best?
- A. What is your reason for wanting such a plan?
- B. Have you talked with your provider about this?
- C. Let us discuss your rights as a couple
- D. Write your ideal plan for the next class
Correct Answer: C
Rationale: Discussion of the provider's role and the couple's rights and limitations in selecting birth options must precede development of a plan.
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For which of the following mother-baby pairs should the nurse review the Coombs' test in preparation for administering Rh0 (D) immune globulin within 72 hours of birth?
- A. Rh negative mother with Rh positive baby
- B. Rh negative mother with Rh negative baby
- C. Rh positive mother with Rh positive baby
- D. Rh positive mother with Rh negative baby
Correct Answer: A
Rationale: Rh negative mother with Rh positive baby. Rh0 (D) immune globulin is administered to prevent Rh sensitization in an Rh-negative mother who may have been exposed to Rh-positive fetal blood during delivery. The Coombs' test helps determine if the baby is Rh-positive, confirming the need for the injection.
A client with hyperthyroidism.
Which of the following actions, if taken by the nurse, is BEST?
- A. Provide the client with extra blankets.
- B. Instill artificial tears prn.
- C. Offer the client reading material.
- D. Offer frequent low-calorie snacks.
Correct Answer: B
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) client is usually sensitive to heat (2) correct-clients with hyperthyroidism frequently exhibit exophthalmos, which requires ophthalmic drops on a regular basis (3) should provide a calm, restful environment with low levels of sensory stimulation, protecting eyes from injury takes priority (4) frequent snacks should be high-calorie
Alcohol and drug abuse impairs judgment and increases risk taking behavior. What nursing diagnosis best applies?
- A. Risk for injury
- B. Risk for knowledge deficit
- C. Altered thought process
- D. Disturbance in self-esteem
Correct Answer: A
Rationale: Risk for injury. Impaired judgment from substance abuse significantly increases the risk of accidents and injuries.
The nurse is preparing to discharge a client with a new diagnosis of asthma.
- A. What is the most important teaching point for a client with a new asthma diagnosis?
- B. Use a spacer with the metered-dose inhaler.
- C. Take the bronchodilator before the corticosteroid.
- D. Avoid exercise to prevent asthma attacks.
- E. Monitor peak flow readings daily.
Correct Answer: D
Rationale: Daily peak flow monitoring helps the client detect early changes in lung function, enabling timely intervention to prevent asthma exacerbations. Using a spacer, proper medication sequencing, and exercise management are important but secondary to ongoing monitoring.
The nurse is caring for a client with a history of chronic obstructive pulmonary disease (COPD) who is receiving oxygen at 2 L/min via nasal cannula. Which of the following findings would be of GREATest concern to the nurse?
- A. Oxygen saturation of 90%.
- B. Respiratory rate of 20 breaths/min.
- C. Temperature of 101°F (38.3°C).
- D. Heart rate of 80 bpm.
Correct Answer: C
Rationale: A temperature of 101°F suggests infection, a serious complication in COPD that can exacerbate respiratory distress. Options A, B, and D are acceptable: oxygen saturation 90% is adequate for COPD, respiratory rate 20 is normal, and heart rate 80 bpm is normal.