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To whom is RhIG (RhoGAM) administered to prevent Rh isoimmunization?
- A. Rh-negative women who deliver an Rh-positive newborn
- B. Rh-positive women who deliver an Rh-negative newborn
- C. Rh-negative newborns whose mothers are Rh positive
- D. Rh-positive fathers before conception of second newborn when first newborn was Rh positive
Correct Answer: A
Rationale: RhIG (RhoGAM) is administered to Rh-negative women who deliver an Rh-positive newborn to prevent Rh isoimmunization. Rh isoimmunization can occur when an Rh-negative mother is exposed to Rh-positive fetal blood during childbirth, leading to the production of antibodies against Rh antigen. RhIG works by binding to and destroying any fetal Rh-positive red blood cells that have entered the mother's circulation, preventing her immune system from mounting an immune response and producing antibodies. This helps to protect subsequent pregnancies from complications related to Rh isoimmunization. Therefore, RhIG administration is crucial in preventing sensitization and ensuring the health of future pregnancies in Rh-negative women who deliver an Rh-positive newborn.
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Which information should the nurse give a mother regarding the introduction of solid foods during infancy?
- A. Solid foods should not be introduced until 8 to 10 months, when the extrusion reflex begins to disappear.
- B. Foods should be introduced one at a time, at intervals of 4 to 7 days.
- C. Solid foods can be mixed in a bottle to make the transition easier for the infant.
- D. Fruits and vegetables should be introduced into the diet first.
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A newborn's mother is alarmed to find small amounts of blood on her infant girl's diaper. When the nurse checks the infant's urine it is straw colored and has no offensive odor. Which explanation to the newborn's mother is most appropriate?
- A. "It appears your baby has a kidney infection"
- B. "Breast-fed babies often experience this type of bleeding problem due to lack of vitamin C in the breast milk"
- C. "The baby probably passed a small kidney stone"
- D. "Some infants experience menstruation like bleeding when hormones from the mother are not available"
Correct Answer: D
Rationale: The most appropriate explanation to the newborn's mother is option D, "Some infants experience menstruation-like bleeding when hormones from the mother are not available." This condition is known as neonatal menstrual-like bleeding or pseudo-menstruation. During pregnancy, babies are exposed to the mother's hormones in the womb. After birth, when the hormonal influence from the mother decreases, some female infants may experience vaginal bleeding, which can be seen in their diapers. This type of bleeding is usually benign and resolves on its own without any intervention. It is not a cause for concern and does not indicate any serious health issue. The straw-colored urine with no offensive odor is a normal finding and further supports the explanation of neonatal menstrual-like bleeding in this case.
A nurse is assigned to four children of different ages. In which age group should the nurse understand that body integrity is a concern? TestBankWorld.org
- A. Toddler
- B. Preschooler
- C. School-age child
- D. Adolescent
Correct Answer: D
Rationale: Body integrity becomes a concern in adolescence, which is the period of development marked by rapid physical changes and self-awareness. Adolescents may experience body image issues, peer pressure, and the desire to conform to societal standards, which can lead to behaviors that compromise their body integrity, such as risky behaviors, eating disorders, self-harm, or seeking cosmetic procedures. By understanding the concerns surrounding body integrity in adolescents, the nurse can provide appropriate support, education, and guidance to promote healthy body image and self-esteem.
The multilumen pulmonary artery catheter allows the nurse to measure hemodynamic pressures at different points in the heart. When the tip enters the small branches of the pulmonary artery, the nurse can assess all of the following except:
- A. Central venous pressure (CVP)
- B. Pulmonary artery capillary pressure (PACP)
- C. Pulmonary artery obstructive pressure (PACP)
- D. Pulmonary artery wedge pressure (PAWP)
Correct Answer: C
Rationale: The multilumen pulmonary artery catheter, when positioned in the small branches of the pulmonary artery, allows the nurse to measure various hemodynamic pressures. Central venous pressure (CVP), Pulmonary artery capillary pressure (PACP), and Pulmonary artery wedge pressure (PAWP) can be measured accurately at this point. However, "Pulmonary artery obstructive pressure" is not a valid or recognized hemodynamic pressure parameter. Instead, the correct term for this measurement that can be assessed using the catheter is the Pulmonary artery occlusion pressure (PAOP) or Pulmonary artery wedge pressure (PAWP), which reflects the left atrial pressure.
Nurse Karen is caring for a client with chronic renal failure. Which is a correct intervention for hyperkalemia?
- A. assess patient for fever and chest pain
- B. assess patient for muscle weakness, diarrhea and ECG changes
- C. encourage compliance with fluid restriction
- D. prepare patient for cardiac ultrasound
Correct Answer: B
Rationale: Hyperkalemia is a common complication in patients with chronic renal failure due to the kidneys' inability to excrete potassium efficiently. The correct intervention for hyperkalemia includes assessing the patient for muscle weakness, diarrhea, and ECG changes. Muscle weakness is a common symptom of hyperkalemia due to its effects on neuromuscular function. Diarrhea can lead to potassium loss from the gastrointestinal tract, helping to lower potassium levels. ECG changes are essential to monitor in hyperkalemia as high potassium levels can result in life-threatening cardiac arrhythmias. By identifying these signs and symptoms early, appropriate interventions can be initiated promptly, such as administering medications to lower potassium levels or adjusting the patient's diet to limit potassium intake.