Nokea
What is the priority action for a newborn with a positive Coombs test?
- A. Begin phototherapy immediately
- B. Monitor for jaundice progression
- C. Administer immunoglobulin therapy
- D. Initiate exchange transfusion procedures
Correct Answer: B
Rationale: Monitoring jaundice progression is crucial for managing hemolytic disease.
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What intervention is highest priority for a woman entering the emergency department after a stranger rape?
- A. Create a safe environment.
- B. Offer postcoital contraceptive therapy.
- C. Provide sexually transmitted disease prophylaxis.
- D. Take a thorough health history.
Correct Answer: A
Rationale: Ensuring safety is paramount immediately after trauma.
What behavior indicates effective teaching about the temperature rhythm method of fertility control?
- A. The woman takes her basal body temperature before retiring each evening.
- B. The couple charts information from at least six menstrual cycles before using the method.
- C. The couple resumes having intercourse as soon as they see a rise in the basal body temperature.
- D. The woman assesses her vaginal discharge daily for changes in color and odor.
Correct Answer: B
Rationale: Charting multiple cycles helps identify the fertile window accurately.
A nurse on a labor unit is admitting a client who reports painful contractions. The nurse determines that the contractions have a duration of 1 min and a frequency of 3 min. The nurse obtains the following vital signs: fetal heart rate 130/min, maternal heart rate 128/min and maternal blood pressure 92/54 mm Hg. Which of the following is the priority action for the nurse to take?
- A. Notify the provider of the findings.
- B. Position the client with one hip elevated.
- C. Ask the client if she needs pain medication.
- D. Have the client void.
Correct Answer: A
Rationale: The priority action for the nurse in this situation is to notify the provider of the vital signs and the client's condition. The maternal blood pressure of 92/54 mm Hg is low, which can indicate hypotension. Hypotension during labor can lead to decreased perfusion to both the mother and baby, potentially causing harm. Therefore, the provider needs to be notified promptly so that appropriate interventions can be initiated to address the maternal hypotension and ensure the well-being of both the mother and the baby. Positioning the client with one hip elevated, asking about pain medication, and having the client void can be important interventions, but they are not the priority in this situation where maternal hypotension is a concern.
What physical findings would the nurse expect to see in a woman diagnosed with primary syphilis?
- A. Cluster of vesicles.
- B. Pain-free lesion.
- C. Macular rash.
- D. Foul-smelling discharge.
Correct Answer: B
Rationale: A pain-free chancre is characteristic of primary syphilis.
When integrating the principles of family-centered care, the nurse would include which concept?
- A. Parents want nurses to make decisions about their child's treatment.
- B. Families are unable to make informed choices.
- C. People have taken increased responsibility for their own health.
- D. Families require little information to make appropriate decisions.
Correct Answer: C
Rationale: Due to the influence of managed care, the focus on prevention, better education, and technological advances, people have taken increased responsibility for their own health.