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The nurse is teaching the postpartum client about newborn transitional stool. Which should the nurse include in the teaching session? SATA
- A. They have greenish brown color
- B. They are looser consistency
- C. They are seedy with sweet sour smell
- D. They have tar like consistency
Correct Answer: A
Rationale: The correct answer is A because transitional stools in newborns typically have a greenish-brown color due to the presence of meconium and the changing composition of the stool as the baby starts digesting breastmilk or formula.
Rationale:
1. A: Greenish-brown color is characteristic of transitional stools as meconium is being passed out.
Incorrect answers:
2. B: Transitional stools are not necessarily looser in consistency.
3. C: Transitional stools are not typically described as seedy with a sweet-sour smell.
4. D: Tar-like consistency is more indicative of meconium, not transitional stools.
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As the infant nursery nurse, you are assisting with a
- A. Assess the fetal station delivery. After the initial assessment of the baby,
- B. Assess for rupture of the fetal membranes what is the next best action?
- C. Determine dilation of the cervix
- D. Give the infant a bath
Correct Answer: C
Rationale: Rationale for Correct Answer (C - Determine dilation of the cervix):
1. It is crucial to monitor the progress of labor by assessing cervical dilation.
2. Cervical dilation indicates the stage of labor and helps determine when the mother is ready to push.
3. This information guides the healthcare team in providing appropriate care and support during delivery.
4. Assessing fetal station or rupture of membranes is important but determining cervical dilation is the priority.
Summary:
- Option A is incorrect because assessing fetal station is not the immediate next step.
- Option B is incorrect as assessing for rupture of membranes is important but not the next immediate action.
- Option D is incorrect as giving the infant a bath is not a priority in the labor and delivery process.
What statement by a health-care provider is an example of shared decision making between a health-care provider and a patient?
- A. I'm going to start this medication because it is best for your baby.
- B. Can you agree with me because I am your health-care provider?â€
- C. I understand how the hospital works, and it will be easier for you to just do what is easy for the nurses.â€
- D. Do you feel ready to make a decision after we talked about this medication?â€
Correct Answer: D
Rationale: The correct answer is D because it involves the patient in the decision-making process by asking for their readiness to make a decision after discussing the medication. This approach respects the patient's autonomy and encourages them to actively participate in their healthcare choices.
A is incorrect as it does not involve the patient in the decision-making process but rather imposes the provider's choice. B is incorrect as it uses authority to influence the patient's decision, which is not in line with shared decision making. C is incorrect as it focuses on convenience rather than involving the patient in the decision-making process.
The nurse is educating a prenatal client about weight dysphoric disorder. Which statement by the client gain during pregnancy. Which statement by the would require immediate follow-up? client indicates effective understanding?
- A. I have been crying the week of my period.
- B. I should gain 2 to 4 pounds in the first trimester
- C. I am experiencing suicidal thoughts. and half a pound per week in the last two
- D. My menstrual cycle is 1 week late. trimesters.
Correct Answer: C
Rationale: Correct Answer: C. "I am experiencing suicidal thoughts."
Rationale: This statement indicates a serious mental health concern that requires immediate follow-up. Suicidal thoughts during pregnancy can be a sign of depression or other mental health issues that need to be addressed promptly to ensure the safety and well-being of the client and the baby.
Summary of Other Choices:
A: "I have been crying the week of my period." - This statement suggests premenstrual symptoms which are common and not necessarily alarming during pregnancy.
B: "I should gain 2 to 4 pounds in the first trimester and half a pound per week in the last two trimesters." - This statement reflects a correct understanding of weight gain recommendations during pregnancy and does not raise immediate concerns.
D: "My menstrual cycle is 1 week late." - This statement is not concerning during pregnancy as menstrual cycles typically stop during pregnancy.
The nurse is monitoring a client with hypertonic uterine contractions. What is the priority nursing action?
- A. Administer pain relief as prescribed.
- B. Prepare for an amniotomy.
- C. Encourage ambulation.
- D. Increase oxytocin infusion.
Correct Answer: A
Rationale: The correct answer is A: Administer pain relief as prescribed. The priority is to address the client's discomfort and pain caused by hypertonic uterine contractions. Pain management is crucial to ensure the client's comfort and well-being. Administering pain relief can help prevent complications such as increased stress on the mother and fetus.
Choice B: Prepare for an amniotomy is incorrect because it involves artificial rupturing of the amniotic sac, which is not indicated for hypertonic contractions.
Choice C: Encourage ambulation is incorrect because it may exacerbate the pain and discomfort experienced by the client with hypertonic uterine contractions.
Choice D: Increase oxytocin infusion is incorrect because it can further intensify the uterine contractions and worsen the client's pain.
16wks gestation reports for a triple screen test. What statements determines understanding?
- A. "This test can be used as a screening for spina bifida."
- B. "This test is a screen test, and I will need other testing if I have abn results."
- C. "this test can indicate if I may be at an increased risk for having a child with down syndrome."
- D. A triple screen test is a screening tool. Maternal blood is drawn and alpha-fetoprotein, hcg, and estriol values are assessed to determine if the mother is at an increased risk for neural tube defects or chromosomal trisomy's. Spina bifida and downs syndrome are the two most common risks.
Correct Answer: D
Rationale: Step-by-step rationale for why answer D is correct:
1. A triple screen test includes assessing alpha-fetoprotein, hCG, and estriol levels.
2. These values help determine the risk for neural tube defects and chromosomal trisomies.
3. The test does not directly diagnose spina bifida but assesses neural tube defects.
4. Down syndrome risk is also evaluated, not diagnosed directly.
5. Answer D provides a comprehensive explanation of the test components and its purpose, aligning with the test's actual function.
Summary of why other choices are incorrect:
A. Incorrect because the test screens for neural tube defects and chromosomal trisomies, not just spina bifida.
B. Incorrect because the test is a screening tool for specific conditions, not a definitive diagnostic test.
C. Incorrect because the test assesses multiple conditions, not just Down syndrome specifically.