Nokea
The physician has ordered an injection of RhoGam for the postpartum client whose blood type is A negative but whose baby is O positive. To provide postpartum prophylaxis, RhoGam should be administered:
- A. Within 72 hours of delivery
- B. Within 1 week of delivery
- C. Within 2 weeks of delivery
- D. Within 1 month of delivery
Correct Answer: A
Rationale: RhoGam must be administered within 72 hours postpartum to prevent Rh sensitization.
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Damage to the VII cranial nerve results in:
- A. Facial pain
- B. Absence of ability to smell
- C. Absence of eye movement
- D. Tinnitus
Correct Answer: C
Rationale: The VII cranial nerve (facial nerve) controls facial muscles; damage causes facial paralysis, affecting eye movement (e.g., inability to close the eye).
A client who just delivered is concerned about her neonate's Apgar scores of 7 at 1 minute and 8 at 5 minutes. She has been told a score lower than 9 is associated with learning disabilities. Which response is best?
- A. Your infant is fine. Don't worry.
- B. Apgar scores indicate a need for extra medical care at birth. Your baby's score of 7 is fine.
- C. There are many good special education programs available I can recommend.
- D. I'll ask the physician to speak with you.
Correct Answer: B
Rationale: Apgar scores of 7 and 8 are within normal limits, indicating no immediate need for extra care, and this response addresses the mother's concern accurately without dismissing it.
Which laboratory test would be the least effective in making the diagnosis of a myocardial infarction?
- A. AST
- B. Troponin
- C. CK-MB
- D. Myoglobin
Correct Answer: A
Rationale: AST is less specific for myocardial infarction than troponin, CK-MB, or myoglobin.
A client with hypothyroidism frequently complains of feeling cold. The nurse should tell the client that she will be more comfortable if she:
- A. Uses an electric blanket at night
- B. Dresses in extra layers of clothing
- C. Applies a heating pad to her feet
- D. Takes a hot bath morning and evening
Correct Answer: B
Rationale: Dressing in extra layers of clothing is a safe and effective way to manage cold intolerance in hypothyroidism, avoiding risks associated with electric blankets or heating pads.
A client admitted with hepatic encephalopathy continues to attempt ambulation without assistance despite repeated instruction. Which intervention should the nurse take to promote safety?
- A. administer Xanax 6 mg PO
- B. apply a vest restraint device
- C. request a family member stay with the client around the clock
- D. move the client closer to the nurses' station
Correct Answer: D
Rationale: Moving the client closer to the nurses’ station allows frequent monitoring, promoting safety without restraints or sedation, which are less appropriate.