Nokea
The nurse performs Leopold's maneuvers for a client admitted in labor. Which is the main goal of Leopold's maneuvers?
- A. To determine whether the client's cervix has dilated
- B. To assess the frequency and intensity of the contractions
- C. To assess whether membranes have been ruptured
- D. To determine the presentation and position of the fetus
Correct Answer: D
Rationale: The correct answer is D: To determine the presentation and position of the fetus. Leopold's maneuvers involve a series of palpations to assess the fetal lie, presentation, position, and engagement. By performing these maneuvers, the nurse can determine the position of the fetus in relation to the mother's pelvis and whether the baby is in a vertex or breech presentation. This information is crucial in planning for a safe delivery and identifying any potential complications.
Other choices are incorrect because:
A: Leopold's maneuvers do not directly assess cervical dilation.
B: Contractions are typically monitored separately using a tocodynamometer.
C: Checking for ruptured membranes is done through a separate assessment.
In summary, Leopold's maneuvers primarily focus on assessing the presentation and position of the fetus to guide the delivery process effectively.
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A nurse is providing teaching for a client who has a new prescription for combined oral contraceptives. Which of the following findings should the nurse include as an adverse effect of this medication?
- A. Depression
- B. Polyuria
- C. Hypotension
- D. Urticaria
Correct Answer: A
Rationale: The correct answer is A: Depression. Combined oral contraceptives are known to potentially cause mood changes, including depression, in some individuals due to hormonal fluctuations. This adverse effect is important for the nurse to include in teaching to monitor the client's mental health. Polyuria (B) is excessive urination, which is not typically associated with oral contraceptives. Hypotension (C) is low blood pressure, which is not a common side effect of this medication. Urticaria (D) is hives or skin rash, which is not a typical adverse effect of combined oral contraceptives.
In a child diagnosed with Tetralogy of Fallot, which of the following is a compensatory mechanism to decrease venous return to the heart?
- A. Squatting
- B. Clubbing
- C. Shortness of breath
- D. Polycythemia
Correct Answer: A
Rationale: Squatting is a compensatory mechanism that decreases venous return (deoxygenated blood) to the heart. This clinical sign is commonly seen in young children with Tetralogy of Fallot, a type of cyanotic heart disease. Squatting helps reduce the workload on the heart by decreasing the amount of deoxygenated blood returning to it.
A nurse is discussing nutrition with an adolescent who is pregnant.
- A. "I told my daughter that any calories ingested are a source of energy and nutrition."'
- B. "I try to provide foods with an increased amount of calcium,protein and iron."'
- C. "I encourage between-meal snacks that are complex carbohydrates and fruits."'
- D. "I have planned meals and snacks for additional calories in the second and third trimester."'
Correct Answer: A
Rationale: Step 1: A is correct because it emphasizes the importance of calorie intake for energy and nutrition during pregnancy.
Step 2: Adolescents have higher calorie needs during pregnancy, making this advice crucial.
Step 3: B focuses on specific nutrients but doesn't address overall calorie intake.
Step 4: C mentions healthy snacks but doesn't emphasize the importance of calories.
Step 5: D mentions additional calories but lacks the focus on all calories being essential.
Step 6: A provides a comprehensive approach to nutrition during pregnancy, making it the correct choice.
A nurse is caring for a 23-month-old child with iron-deficiency anemia.
- A. "Give the oral iron supplementation with a glass of cow's milk to prevent stomach problems."'
- B. "Provide diet instructions including limiting citrus fruits in favor of more vegetables."'
- C. "Provide information about complications of iron including gastrointestinal bleeding and ulcers."'
- D. "Give liquid iron through a straw placed in the back of the mouth."'
Correct Answer: D
Rationale: Correct Answer: D
Rationale:
1. Iron supplements can stain teeth, so giving liquid iron through a straw placed in the back of the mouth minimizes contact with teeth.
2. This method also helps reduce the risk of tooth decay and enamel erosion.
3. Providing iron through a straw allows for better absorption through the bloodstream.
4. It is important to maximize iron absorption in children with iron-deficiency anemia.
Summary of other choices:
A. Giving iron supplementation with cow's milk can reduce iron absorption due to calcium interference.
B. Diet instructions should focus on iron-rich foods, not just limiting citrus fruits.
C. While complications of iron deficiency should be discussed, this choice does not address treatment.
A nurse is caring for a child with muscular dystrophy. Which of the following priority actions should the nurse include in the care of this child?
- A. Limit physical activity and plan frequent rest periods to avoid overexertion and exhaustion of muscle groups.
- B. Recommend genetic counseling for parents,male siblings and paternal uncles and their male offspring.
- C. Advise against flu and pneumococcal vaccines due to a compromised respiratory system.
- D. Have the child use an incentive spirometer and perform breathing exercises routinely.
Correct Answer: D
Rationale: The correct answer is D: Have the child use an incentive spirometer and perform breathing exercises routinely. This is the priority action because children with muscular dystrophy are at risk for respiratory complications due to weakened respiratory muscles. Using an incentive spirometer and performing breathing exercises help maintain lung function and prevent respiratory infections.
A: Limiting physical activity and planning rest periods is important, but respiratory care takes precedence in muscular dystrophy.
B: Genetic counseling is important for family planning but does not directly impact the child's care.
C: Advising against vaccines can increase the risk of infections in a child with compromised respiratory function.
E, F, G: No information provided.