Nokea
What nursing action will the nurse implement after feeding an infant with hydrocephalus?
- A. Position the infant sitting upright in an infant seat
- B. Place the infant over the shoulder to burp
- C. Leave the infant in a side-lying position
- D. Stimulate the infant by rubbing its feet
Correct Answer: C
Rationale: The correct answer is C: Leave the infant in a side-lying position. This is important for infants with hydrocephalus as it helps prevent aspiration and reflux. Placing the infant in an upright position (Choice A) may increase the risk of regurgitation and aspiration. Burping (Choice B) is important after feeding but may not specifically address the needs of an infant with hydrocephalus. Stimulating the infant by rubbing its feet (Choice D) is unrelated to the specific care needed for an infant with hydrocephalus.
You may also like to solve these questions
A client comes to a community clinic after being informed by a sexual partner of possible recent exposure to syphilis. The nurse will examine the client for which clinical manifestation of syphilis in the primary stage?
- A. Chancre
- B. Copper-colored rash involving the trunk and extremities
- C. Flulike symptoms
- D. Condyloma lata
Correct Answer: A
Rationale: The correct answer is A: Chancre. In the primary stage of syphilis, a painless, firm, and non-itchy sore called a chancre appears at the site of infection. This sore can develop within 3 weeks of exposure to the bacteria. It is important for the nurse to examine the client for chancres as they are a hallmark sign of primary syphilis.
B: A copper-colored rash involving the trunk and extremities is seen in the secondary stage of syphilis, not the primary stage.
C: Flulike symptoms may occur in the primary stage but are not specific to syphilis.
D: Condyloma lata are wart-like growths seen in secondary syphilis, not the primary stage.
Therefore, the presence of a chancre is the key clinical manifestation to identify in the primary stage of syphilis.
An absence of what may facilitate the occurrence of bacterial vaginosis?
- A. Antibodies
- B. Lactobacillus acidophilus
- C. Gardnerella vaginalis
- D. Vaginal mucosa
Correct Answer: B
Rationale: Correct Answer: B - Lactobacillus acidophilus
Rationale: Lactobacillus acidophilus is a beneficial bacteria that helps maintain the acidic pH of the vagina, inhibiting the growth of harmful bacteria like Gardnerella vaginalis. An absence of Lactobacillus acidophilus can disrupt the vaginal microbiota balance, allowing for the overgrowth of harmful bacteria and leading to bacterial vaginosis.
Summary of Incorrect Choices:
A: Antibodies - Antibodies play a role in the immune response but are not directly related to the occurrence of bacterial vaginosis.
C: Gardnerella vaginalis - Gardnerella vaginalis is a bacteria associated with bacterial vaginosis, not its absence.
D: Vaginal mucosa - The integrity of the vaginal mucosa is important for protection, but its absence would not directly facilitate bacterial vaginosis.
According to the standard staging classification for breast cancer, which criteria reflects stage 2 breast cancer?
- A. Tumor smaller than 2 cm, no regional lymph node metastasis, no distant metastasis
- B. No evidence of tumor; metastasis to lymph nodes fixed to one another or to other structure but no distant metastasis
- C. Tumor larger than 5 cm; metastasis to lymph nodes fixed to one another or to other structure; no distant metastasis
- D. Tumor larger than 2 to 5 cm; no regional lymph node metastasis; no distant metastasis
Correct Answer: D
Rationale: The correct answer is D because it aligns with the criteria for stage 2 breast cancer in the standard staging classification. In stage 2, the tumor is typically larger than 2 cm but not larger than 5 cm, there is no regional lymph node metastasis, and there are no distant metastases. Option A is incorrect because the tumor size is smaller than 2 cm, which does not meet the criteria for stage 2. Option B is incorrect as it describes no evidence of tumor with lymph node metastasis, which does not represent stage 2. Option C is incorrect as the tumor size is larger than 5 cm, exceeding the criteria for stage 2.
A 32-week-gestation client was last seen in the prenatal clinic at 28 weeks' gestation. Which of the following changes should the nurse bring to the attention of the certified nurse midwife?
- A. Weight change from 128 pounds to 138 pounds.'
- B. Pulse rate change from 88 bpm to 92 bpm.'
- C. Blood pressure change from 120/80 to 118/78.'
- D. Respiratory rate change from 16 rpm to 20 rpm.'
Correct Answer: A
Rationale: The correct answer is A because a weight gain of 10 pounds in 4 weeks for a 32-week-gestation client is excessive and may indicate a potential issue such as gestational diabetes or preeclampsia.
B: The pulse rate change is within a normal range for pregnancy.
C: The blood pressure change is minimal and still within normal limits.
D: The respiratory rate change is also within normal limits for pregnancy.
A public health nurse is teaching a group about STIs at a local community center. Which statement made by the group demonstrates a good understanding of the disease process?
- A. The infection can only be spread when a person is symptomatic.
- B. I can only get the disease through vaginal intercourse.
- C. Sexual partners of the infected person must also be treated.
- D. Oral contraceptives are effective in protecting against STIs.
Correct Answer: C
Rationale: The correct answer is C: Sexual partners of the infected person must also be treated. This statement demonstrates a good understanding of the disease process because treating only the infected person may not prevent re-infection. Treating sexual partners is crucial to prevent the spread of STIs and reduce the risk of transmission. This approach is known as partner therapy and is recommended by public health guidelines to control the spread of STIs effectively. It is important to address the source of infection and not just the individual who is currently infected.
Incorrect Choices:
A: The infection can only be spread when a person is symptomatic - This is incorrect because some STIs can be transmitted even when the infected person is asymptomatic.
B: I can only get the disease through vaginal intercourse - This is incorrect as STIs can be transmitted through various sexual activities, not just vaginal intercourse.
D: Oral contraceptives are effective in protecting against STIs - This is incorrect as oral contraceptives do not protect against STIs;