Nokea
The nursery nurse delays the first bottle feeding of a newborn. Which is the most common reason for the nurse's actions? The infant has:
- A. a blood glucose of 45 gm/dL
- B. a respiratory rate above 60
- C. blue hands and feet
- D. a heart murmur
Correct Answer: B
Rationale: The correct answer is B: a respiratory rate above 60. The nurse delays feeding because a high respiratory rate may indicate respiratory distress, making feeding unsafe. Feeding can lead to aspiration in infants with respiratory issues. A blood glucose of 45 gm/dL (choice A) is low but not typically a reason to delay feeding. Blue hands and feet (choice C) may indicate poor circulation, but it's not a common reason to delay feeding. A heart murmur (choice D) doesn't directly impact feeding safety.
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The nurse notices a variable deceleration on a fetal monitor strip. Which nursing action is appropriate?
- A. Instruct the mother to breathe slowly because this is a sign of hyperventilation
- B. Decrease the amount of Pitocin because this is a sign of hypertonic uterine contractions
- C. Turn the woman onto her left side to relieve pressure on the umbilical cord
- D. Reduce the oral and IV fluids to decrease circulatory overload
Correct Answer: C
Rationale: The correct answer is C: Turn the woman onto her left side to relieve pressure on the umbilical cord. Variable decelerations are associated with umbilical cord compression. Turning the woman onto her left side can help relieve pressure on the cord, improving fetal oxygenation. This position change is a non-invasive, quick intervention that can potentially resolve the variable decelerations.
Choice A is incorrect because variable decelerations are not typically associated with hyperventilation. Choice B is incorrect as decreasing Pitocin may not directly address the underlying cause of the variable decelerations. Choice D is incorrect because reducing fluids may not address the immediate concern of umbilical cord compression.
A client reports awaking from sleep by contractions that are occurring every five minutes and lasting 30-40 seconds. Which of the following questions should the nurse ask to assess for true labor versus false labor?
- A. When did your contractions begin?
- B. Have you noticed any bloody show or fluid coming from your vagina?
- C. What happens to your contractions when you move about?
- D. Have you felt fetal movement over the last 24 hours?
Correct Answer: B
Rationale: The correct answer is B. The presence of bloody show or fluid coming from the vagina can indicate ruptured membranes, which is a sign of true labor. This is important in determining whether the client is in active labor. Asking about the presence of bloody show or fluid helps differentiate between true and false labor.
Choice A is less relevant as the timing of contractions alone does not distinguish between true and false labor. Choice C is related to assessing the effectiveness of contractions, not differentiating between true and false labor. Choice D is important for assessing fetal well-being but does not help in distinguishing between true and false labor.
For a pregnant adolescent who is anemic, which foods should the nurse include in the client's dietary plan to increase iron levels?
- A. Milk and fish
- B. Chicken and cottage cheese
- C. Orange juice and apricots
- D. Pickles and peanut butter sandwiches
Correct Answer: C
Rationale: The correct answer is C: Orange juice and apricots. Orange juice is a good source of Vitamin C, which enhances iron absorption. Apricots are high in iron, helping to increase iron levels in the body. Milk and fish (choice A) contain little iron. Chicken and cottage cheese (choice B) are not significant sources of iron. Pickles and peanut butter sandwiches (choice D) lack iron and Vitamin C.
A nurse is discussing the use of condoms with a female client. Which of the following statements by client represents a need for further teaching?
- A. My partner will put the condom on while his penis is erect.
- B. I will remove the condom 30 minutes after intercourse.
- C. My partner should leave an empty space at the tip.
- D. I can use spermicidal gels or creams to increase effectiveness.
Correct Answer: B
Rationale: The correct answer is B because condoms should be removed immediately after intercourse to prevent leakage of semen. Leaving the condom on for 30 minutes increases the risk of pregnancy and STIs. Choice A is correct as condoms should be put on when the penis is erect. Choice C is correct as leaving a space at the tip allows room for semen collection. Choice D is incorrect as spermicidal gels or creams are not recommended due to potential irritation and increased risk of STIs.
A client, gravida 1, para 0, in active labor, is becoming increasingly anxious. Which statement by the nurse will block therapeutic communication with the client?
- A. What concerns are you having now?
- B. Tell me how you are feeling.
- C. Everything is going just fine.
- D. You seem a little nervous.
Correct Answer: C
Rationale: Correct Answer: C
Rationale:
1. Choice A and B encourage the client to express their concerns and feelings, promoting therapeutic communication.
2. Choice D acknowledges the client's emotions, showing empathy and understanding.
3. Choice C dismisses the client's anxiety, invalidating their feelings, hindering communication.
Summary:
Choices A, B, and D promote open communication and empathy, while choice C ignores the client's anxiety, making it the incorrect choice.