Nokea
The nurse is teaching umbilical cord care to a new mother. What information should the nurse provide to the mother related to cord care?
- A. Alcohol is the only agent to use to clean the cord.
- B. Cord care is done only at birth to control bleeding.
- C. It takes at least 21 days for the cord to dry up and fall off.
- D. The process of keeping the cord clean and dry will decrease bacterial growth.
Correct Answer: D
Rationale: The cord should be kept clean and dry to decrease bacterial growth. It should be cleansed two to three times a day with a prescribed agent. Usually the cord is cleansed with soap and water around base of the cord where it joins the skin. The primary health care provider is notified of any odor, discharge, or skin inflammation. The diaper should not cover the cord because a wet or soiled diaper will slow or prevent drying of the cord and foster infection. Cord care is required until the cord dries up and falls off between 7 and 14 days after birth.
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A battered woman seen in the emergency department requires tertiary intervention because of repeated abuse. Which nursing interventions are appropriate? Select all that apply.
- A. Report the abuse to the police.
- B. Provide medications to relieve pain and anxiety.
- C. Explore family and friends as support possibilities.
- D. Focus on the woman's strengths, endurance, and abilities.
- E. Avoid discussing the implications of pressing charges against the batterer.
- F. Discourage the woman from discussing the events leading to past and present abuse situations.
Correct Answer: A,B,C,D
Rationale: Tertiary prevention for repeated abuse focuses on overcoming physical and psychological effects and preventing future abuse. Appropriate interventions include reporting abuse to ensure safety, providing medications for pain and anxiety, exploring support options, and focusing on the woman's strengths to boost self-esteem. Avoiding discussions about pressing charges or past events is not helpful, as these help address implications and reduce guilt.
The nurse is talking to a 67-year-old client who has just retired from the job he's had since age 17-the only job he's ever had. The nurse understands that the client is in which of Erikson's stages?
- A. intimacy versus isolation
- B. ego integrity versus despair
- C. identity versus role confusion
- D. generativity versus stagnation
Correct Answer: B
Rationale: A 67-year-old retiree is in Erikson's ego integrity versus despair stage, reflecting on life's accomplishments.
The nurse reviews the pattern of a nonstress test performed on a pregnant client and interprets the finding as which result? (Refer to figure.)
- A. Reactive
- B. Abnormal
- C. Nonreactive
- D. Non-reassuring
Correct Answer: A
Rationale: A nonstress test assesses fetal well-being and evaluates the ability of the fetal heart to accelerate, often in association with fetal movement. Accelerations of the fetal heart rate are associated with adequate oxygenation, a healthy neural pathway, and the fetal heart's ability to respond to stimuli. A reactive test is described as at least two fetal heart rate accelerations, with or without fetal movement, occurring within a 20-minute period and peaking at least 15 beats/minute above the baseline and lasting 15 seconds from baseline to baseline. This recording (see figure) identifies a reactive nonstress test. The fetal heart rate acceleration peaks at least 15 beats/minute and lasts for at least 15 seconds in response to fetal movement. A nonreactive test is an abnormal or nonreassuring test. In a nonreactive test, the recording does not demonstrate the required characteristics of a reactive test within a 40-minute period.
The nurse is teaching health education classes to a group of expectant parents, and the topic is preventing cognitive impairment caused by congenital hypothyroidism. What should the nurse tell the parents is the most effective means of promoting early intervention?
- A. Vitamin intake
- B. Neonatal screening
- C. Adequate protein intake
- D. Limiting alcohol consumption
Correct Answer: B
Rationale: Congenital hypothyroidism is a common preventable cause of cognitive impairment. Neonatal screening is the only means of early diagnosis followed by intervention and the subsequent prevention of cognitive impairment. Newborn infants are screened for congenital hypothyroidism before discharge from the newborn nursery and before 7 days of life. Treatment is begun immediately, if necessary. Vitamin intake and adequate protein will not specifically prevent this disorder. Alcohol consumption during pregnancy needs to be restricted rather than just limited.
The home care nurse visits a child diagnosed with scarlet fever who is being treated with penicillin G potassium. The mother tells the nurse that the child has only voided a small amount of tea-colored urine since the previous day. The mother also reports that the child's appetite has decreased and that the child's face was swollen this morning. How should the nurse interpret these new signs/symptoms?
- A. Nothing to be concerned about
- B. Signs/symptoms of acute glomerulonephritis
- C. Signs/symptoms of the normal progression of scarlet fever
- D. Symptoms of an allergic reaction to penicillin G potassium
Correct Answer: B
Rationale: Scarlet fever is an infectious and communicable disease caused by group A beta-hemolytic streptococci. The signs/symptoms identified in the question indicate acute glomerulonephritis, indicative of nephrotoxicity. These signs/symptoms are not normal and should not be ignored. Although the child is receiving penicillin G potassium, these are not signs/symptoms of an allergic reaction.