Nokea
The nurse makes a home visit to a primiparous client and her neonate at 1 week after a vaginal delivery. Which of the following findings should be reported to the physician?
- A. A scant amount of maternal lochia serosa.
- B. The presence of a neonatal tonic neck reflex.
- C. A nonpalpable maternal fundus.
- D. Neonatal central cyanosis.
Correct Answer: D
Rationale: Neonatal central cyanosis indicates possible respiratory or cardiac issues and requires immediate reporting. The other findings are normal at 1 week postpartum.
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A parent reports that her child has developed a bloody nose. Which action should the nurse instruct the parent to take to control the bleeding?
- A. Pinch the nostrils for 5 minutes and then recheck for bleeding.
- B. Maintain the child in a sitting position with the head tilted backward.
- C. Lay the child down with a pillow tucked under the neck and stay with the child to keep the child calm.
- D. Have the child sit with the head tilted forward and hold pressure on the soft part of the nose for a period of 10 minutes.
Correct Answer: D
Rationale: The child should be positioned erect, sitting with head tilted forward to avoid blood dripping posteriorly to the pharynx. The soft part of the nose should be tightly pinched against the center wall for 10 minutes, and the parent should be instructed that this pinch should be timed by a clock, not estimated. The parent should be told not to release pressure for 10 minutes. The child is encouraged to remain calm and quiet and to breathe through the mouth.
A client with a diagnosis of breast cancer is prescribed letrozole (Femara). The nurse should instruct the client to report which of the following side effects immediately?
- A. Hot flashes.
- B. Bone pain.
- C. Nausea.
- D. Fatigue.
Correct Answer: B
Rationale: Bone pain may indicate bone loss or metastasis, a serious side effect of letrozole requiring immediate reporting.
A client has been scheduled for a barium swallow (esophagography). The nurse determines that the client understands preprocedure instructions when the client states the intention to take which action before the test?
- A. Take all oral medications as scheduled.
- B. Eat a regular breakfast on the day of the test.
- C. Monitor own bowel movement pattern for constipation.
- D. Remove metal objects and jewelry, especially from the neck and chest area.
Correct Answer: D
Rationale: A barium swallow, or esophagography, is a radiograph that uses a substance called barium for contrast to highlight abnormalities in the gastrointestinal (GI) tract. The client is told to remove metal objects such as medals and jewelry before the test so that they will not interfere with radiographic visualization of the field. Some oral medications are withheld before the test, and the client should follow the primary health care provider's instructions regarding medication administration. The client should fast for a minimum of 8 hours before the test, depending on primary health care provider's instructions. It is important after the procedure to monitor for constipation, which can occur as a result of the presence of barium in the GI tract.
A client with a history of cirrhosis is admitted with esophageal varices. The nurse should monitor the client for which of the following complications?
- A. Hematemesis.
- B. Hypotension.
- C. Fever.
- D. Constipation.
Correct Answer: A, B
Rationale: Esophageal varices can rupture, causing hematemesis and hypotension.
A 72-year-old client is referred for counseling. During the initial nursing assessment, the client denies the need for counseling. The nurse would agree with the client if she made which of the following comments?
- A. My doctor just put me on an antidepressant, and I'll be fine in a week or so.'
- B. My daughter sent me here. She's mad because I don't have the energy to take care of my grandkids.'
- C. Since I've gotten over the death of my husband, I've had more energy and been more active than before he died.'
- D. My son got worried because I made this silly comment about wanting to be with my husband in heaven.'
Correct Answer: C
Rationale: Increased energy and activity post-grief suggest the client is coping well, supporting her denial of needing counseling.