Nokea
When can a woman who thinks she may be pregnant use a home pregnancy test to diagnose pregnancy?
- A. A home pregnancy test can be used right after your first missed period.
- B. These tests are most accurate after you have missed your second period.
- C. Home pregnancy tests often give false positives and should not be trusted.
- D. The test can provide accurate information when used right after ovulation.
Correct Answer: A
Rationale: The correct answer is A. Home pregnancy tests detect hCG, a hormone produced during pregnancy, and are most accurate after the first missed period when hCG levels are higher. Testing too early may result in a false negative. Waiting until after the first missed period increases the reliability of the test results.
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When performing the daily head-to-toe assessment of a 1-day-old newborn, the nurse observes a yellow tint to the skin on the forehead, sternum, and abdomen. Which action should the nurse take?
- A. Measure bilirubin levels using transcutaneous bilirubinometry.
- B. Evaluate cord blood Coombs test results.
- C. Review maternal medical records for blood type and Rh factor.
- D. Prepare the newborn for phototherapy.
Correct Answer: A
Rationale: The presence of a yellow tint on the skin of a newborn suggests jaundice. The initial step in managing jaundice in a newborn is to measure bilirubin levels, typically done using transcutaneous bilirubinometry. This measurement helps determine the severity of jaundice and guides appropriate treatment interventions. Evaluating cord blood Coombs test results or reviewing maternal medical records for blood type and Rh factor are not the immediate actions indicated when jaundice is suspected. Phototherapy may be considered after confirming elevated bilirubin levels and assessing the need for treatment.
A child with ADHD needs help with homework. What should the nurse encourage the parents to do?
- A. Encourage the parents to help the child with homework.
- B. Do the homework for the child.
- C. Set a regular homework schedule.
- D. Provide a quiet environment for homework.
Correct Answer: A
Rationale: Encouraging parents to help the child with homework is beneficial as it fosters independence and academic skills. This involvement allows the child to receive the necessary support and guidance while still actively participating in their academic responsibilities, promoting a sense of accomplishment and skill development.
Insulin therapy is initiated for a 12-year-old child who is admitted with diabetic ketoacidosis (DKA). Which action is most important for the nurse to include in the child's plan of care?
- A. Monitor serum glucose for adjustment in the infusion rate of regular insulin (Novolin R).
- B. Determine the child's compliance schedule for subcutaneous NPH insulin (Humulin N).
- C. Demonstrate to the parents how to program an insulin pen for daily glucose regulation.
- D. Consult with the healthcare provider about the use of insulin detemir (Levemir Flex Pen).
Correct Answer: A
Rationale: In managing diabetic ketoacidosis (DKA), monitoring serum glucose levels is crucial to adjust the infusion rate of regular insulin effectively. This helps in controlling blood glucose levels and preventing complications associated with DKA. Close monitoring and adjustments based on glucose levels are essential for the successful management of DKA.
A new mother who is breastfeeding her 4-week-old infant and has type 1 diabetes reports that her insulin needs have decreased since the birth of her child. Which action should the nurse implement?
- A. Inform her that a decreased need for insulin occurs while breastfeeding.
- B. Counsel her to increase her caloric intake.
- C. Advise the client to breastfeed more frequently.
- D. Schedule an appointment for the client with the diabetic nurse educator.
Correct Answer: A
Rationale: During breastfeeding, insulin needs often decrease due to the metabolic demands of milk production. Therefore, the nurse should inform the client that this decrease in insulin requirements is a normal response to breastfeeding. It is essential for healthcare providers to educate clients about this physiological change to prevent unnecessary concerns or adjustments to insulin therapy.
An infant with tetralogy of Fallot becomes acutely cyanotic and hyperneic. Which action should the nurse implement first?
- A. Place the infant in a knee-chest position.
- B. Administer morphine sulfate.
- C. Start intravenous fluids.
- D. Provide 100% oxygen by face mask.
Correct Answer: A
Rationale: In a tetralogy of Fallot situation, placing the infant in a knee-chest position is the initial priority to help increase systemic vascular resistance, which reduces the right-to-left shunt and improves oxygenation. This position can assist in optimizing oxygen levels before considering other interventions.