Nokea
The nurse should first implement --- and ---
- A. Providing education on medications.
- B. Administering doxycycline.
- C. Administering ceftriaxone.
- D. Administering metronidazole and educating on condom.
- E. Administering metronidazole.
Correct Answer: B, C
Rationale: The correct answer is B, C. The nurse should first implement administering doxycycline and ceftriaxone in the treatment of certain infections like gonorrhea and chlamydia. Administering these antibiotics promptly is crucial to start the treatment process effectively. Providing education on medications (choice A) can follow once the initial treatment is administered. Administering metronidazole alone (choice E) or with educating on condoms (choice D) is not appropriate for the initial treatment of gonorrhea or chlamydia. Administering metronidazole alone would not effectively address these infections.
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A nurse is assessing a client who gave birth vaginally 12 hr ago and palpates their uterus to the right above the umbilicus. Which of the following interventions should the nurse perform?
- A. Reassess the client in 2 hr.
- B. Administer simethicone.
- C. Assist the client to empty their bladder.
- D. Instruct the client to lie on their right side.
Correct Answer: C
Rationale: The correct answer is C: Assist the client to empty their bladder. After giving birth vaginally, the uterus should be midline and firm. Palpating it above the umbilicus and to the right indicates a full bladder displacing the uterus. Emptying the bladder will allow the uterus to return to its normal position. A: Reassessing in 2 hours is unnecessary as the issue is a full bladder. B: Administering simethicone is for gas relief and not relevant in this situation. D: Instructing the client to lie on their right side does not address the underlying issue of the full bladder.
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 can lead to mood changes, including depression, as a potential adverse effect due to hormonal fluctuations. This is important for the nurse to include in teaching to monitor and address any mental health concerns. Polyuria (increased urination) is not a common adverse effect of combined oral contraceptives. Hypotension (low blood pressure) is not typically associated with this medication. Urticaria (hives) is more commonly seen with allergic reactions rather than as a side effect of oral contraceptives.
A nurse is caring for a client who is at 38 weeks of gestation. Which of the following actions should the nurse take prior to applying an external transducer for fetal monitoring?
- A. Determine progression of dilatation and effacement.
- B. Perform Leopold maneuvers.
- C. Complete a sterile speculum exam.
- D. Prepare a Nitrazine paper test.
Correct Answer: B
Rationale: The correct answer is B: Perform Leopold maneuvers. Prior to applying an external transducer for fetal monitoring, the nurse should perform Leopold maneuvers to assess the fetal position, presentation, lie, and engagement. This helps in determining the optimal placement of the transducer for accurate monitoring of the fetal heart rate. It allows the nurse to locate the fetal back and position the transducer over the fetal heart for the best signal quality.
Choices A, C, and D are incorrect:
A: Determining progression of dilatation and effacement is not necessary before applying the external transducer.
C: Completing a sterile speculum exam is not needed for fetal monitoring.
D: Preparing a Nitrazine paper test is unrelated to applying an external transducer.
Which of the following conditions should the nurse identify as being consistent with the adolescent's assessment findings? For each finding click to specify if the assessment findings are consistent with trichomoniasis, gonorrhea, or candidiasis. Each finding may support more than one disease process.
- A. Abdominal pain.
- B. Greenish discharge.
- C. Diabetes.
- D. Pain on urination.
- E. Absence of condom.
Correct Answer: B, D
Rationale: To determine the correct answer, we look at the assessment findings. For "Greenish discharge," this is consistent with both trichomoniasis and gonorrhea. Trichomoniasis typically presents with a frothy, yellow-green discharge, while gonorrhea can cause a greenish or yellow discharge. "Pain on urination" is also a common symptom of both gonorrhea and trichomoniasis. Therefore, the correct answer is B, D. Abdominal pain is not specific to any of the mentioned conditions and is not a defining symptom. Diabetes is not directly related to the assessment findings provided. The absence of a condom is not a symptom but rather a risk factor for sexually transmitted infections.
A nurse is caring for a newborn who was transferred to the nursery 30 min after birth because of mild respiratory distress. Which of the following actions should the nurse take first?
- A. Confirm the newborn's Apgar score.
- B. Verify the newborn's identification.
- C. Administer vitamin K to the newborn.
- D. Determine obstetrical risk factors.
Correct Answer: B
Rationale: The correct answer is B: Verify the newborn's identification. This should be done first to ensure the right baby is receiving care. Confirming the identity helps prevent errors in medication administration and procedures. Checking the identification is crucial for patient safety. The other options are not the first priority in this scenario. A: Confirming the Apgar score can wait until after ensuring the correct baby is being cared for. C: Administering vitamin K is important, but verifying identification takes precedence. D: Determining obstetrical risk factors can be done later once the baby's identity is confirmed.