Nokea
The nurse receives a newborn within the first minutes after a vaginal delivery and intervenes to establish adequate respirations. Which priority issue should the nurse address to ensure the newborn's survival?
- A. Heat loss.
- B. Fluid balance.
- C. Bleeding tendencies.
- D. Hypoglycemia.
Correct Answer: A
Rationale: Preventing heat loss avoids cold stress, which can lead to respiratory distress and metabolic issues, critical for newborn survival.
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The nurse is providing discharge instructions to the caregiver of an infant with recurrent otitis media. Which statement made by the caregiver should the nurse recognize as needing additional education about minimizing subsequent infections?
- A. Avoid any smoking inside the house.
- B. Give infant the full course of antibiotics.
- C. Schedule visit for pneumococcal vaccine.
- D. Instill benzocaine otic drops regularly.
Correct Answer: D
Rationale: Benzocaine otic drops provide pain relief but do not prevent infections. Regular use may mask symptoms, delaying treatment. Avoiding smoke, completing antibiotics, and vaccinating reduce infection risk.
The nurse is giving instructions to the mother of a 10-year-old boy who is newly diagnosed with type 1 diabetes mellitus (DM). When attempting to teach the mother how to administer subcutaneous insulin injections to the child, the mother tells the nurse that she is afraid of needles and cannot perform the procedure. Which intervention should the nurse implement?
- A. Determine if the child can administer the insulin.
- B. Ask if the father can help with the injections.
- C. Assess the mother's parenting skills.
- D. Encourage the mother to handle the needles.
Correct Answer: D
Rationale: Gradual exposure to needles through practice builds the mother's confidence, ensuring effective insulin administration for diabetes management.
A multiparous client with active herpes lesions is admitted to the unit with spontaneous rupture of membranes. Which action should the nurse take?
- A. Obtain blood cultures.
- B. Administer penicillin.
- C. Prepare for a cesarean section.
- D. Cover the lesion with a dressing.
Correct Answer: C
Rationale: Cesarean section prevents neonatal herpes transmission during delivery with active lesions.
A preschool-aged child who is experiencing respiratory distress is brought to the emergency department by the parents. The child is anxious, has a temperature of 102.8° F (39.3° C), and is drooling from the mouth while leaning forward when sitting. Which action should the nurse implement next?
- A. Begin prescribed intravenous antibiotic administration.
- B. Schedule the child for a STAT magnetic resonance imaging (MRI) of the neck.
- C. Obtain bedside trays for intubation or tracheotomy by the healthcare provider.
- D. Provide a nebulizer treatment with bronchodilators.
Correct Answer: C
Rationale: Symptoms suggest epiglottitis, requiring immediate airway management. Intubation/tracheotomy trays are critical to address potential airway obstruction.
A nurse is speaking with a client who is addicted to heroin and who just learned that she is pregnant. The client states, 'I just started taking methadone. Is there anything else I can do to make sure my baby is healthy?' Which information should the nurse provide?
- A. Describe genetic testing protocols.
- B. Sign up for group therapy sessions.
- C. Start a prenatal care plan as soon as possible.
- D. Discontinue the methadone right away.
Correct Answer: C
Rationale: Early prenatal care monitors methadone effects, fetal development, and complications like neonatal abstinence syndrome, ensuring a healthy pregnancy.