Nokea
The nurse teaches a new mother that neonatal weight loss in the first 3 days of life is most often the result of:
- A. Allergy to formula
- B. a hypoglycemic response
- C. Inadequate breast or formula feeding
- D. Excretion of fluid via lungs, urinary bladder and bowels.
Correct Answer: D
Rationale: Fluid loss is the primary cause of early weight loss.
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The nurse notes that an older adult client receives only one visitor and asks the client if family members could be called. The client states, 'I consider her to be all of my family.' What would the nurse consider in responding to the client?
- A. The nurse could encourage the client to reconnect with other family members.
- B. The client defines who is and who is not part of the family without undue influence.
- C. The nurse realizes individuals exist without a family and do not often adopt substitutes.
- D. Family is more important to those individuals with a large number of family members.
Correct Answer: B
Rationale: It is important for nurses to remain neutral to all they hear and see in order to enhance trust and maintain open communication lines with all family members. Nurses need to remember that clients are experts of their own health and can define their own family.
A nurse is admitting a client who is at 35 weeks of gestation and is experiencing mild vaginal bleeding due to placenta previa. Which of the following actions should the nurse plan to take?
- A. Initiate continuous monitoring of the FHR.
- B. Administer a dose of betamethasone.
- C. Check the cervix for dilation every 8 hr.
- D. Request that the provider prescribe misoprostol PRN.
Correct Answer: A
Rationale: In placenta previa, the placenta partially or completely covers the cervix, which can lead to vaginal bleeding. Continuous monitoring of the fetal heart rate (FHR) is crucial in this situation to assess the well-being of the fetus. Any signs of distress or changes in the FHR can indicate potential complications, such as fetal hypoxia. This monitoring allows for prompt intervention if necessary to ensure the safety of both the mother and the baby. Administering betamethasone may be indicated to promote fetal lung maturity in cases of anticipated preterm birth, but it is not the priority in this scenario where monitoring the fetal well-being is crucial. Checking the cervix for dilation every 8 hours is not necessary and may increase the risk of further bleeding. Misoprostol, a medication used to induce labor, is contraindicated in cases of placenta previa because it can cause further
The nurse is working with a group of community health members to develop a plan to address the special health needs of women. Which educational program would the group most likely identify as the priority?
- A. risk reduction strategies for diabetes
- B. methods for smoking cessation
- C. ways to adopt a heart-healthy lifestyle
- D. importance of cancer screening and early detection
Correct Answer: C
Rationale: The group needs to address cardiovascular disease, the number one cause of death in women regardless of racial or ethnic group. Thus, education for adopting a heart-healthy lifestyle would be the priority.
After her baby's birth a patient wishes to begin breastfeeding. The nurse assists the client by:
- A. Positioning the infant to grasp the nipple to express milk.
- B. Giving the infant a bottle first to evaluate the baby's ability to suck
- C. Leaving them alone and allowing the infant to nurse as long as desired
- D. Touching the infant's cheek adjacent to the nipple to elicit the rooting reflex
Correct Answer: D
Rationale: The rooting reflex helps initiate breastfeeding.
A nurse is caring for a person who is blind. What intervention could the nurse implement to deliver culturally responsive care?
- A. Ask family members to leave the room for the discussion of care.
- B. Be aware of how the person is addressed.
- C. Introduce herself with her name and credentials upon entering the room.
- D. Leave education material in Braille on the table across the room from the bed.
Correct Answer: C
Rationale: Introducing oneself clearly helps build trust and ensures the patient knows who is providing care.