Nokea
A patient's newborn is neurologically impaired. The most important nursing action should be:
- A. Assist the patient and her family with the grieving process.
- B. Perform neurological assessments of the newborn every four hours.
- C. Arrange for social services to discuss possible placement of the newborn
- D. Obtain an order for an antidepressant to help the patient cope with the depressing news.
Correct Answer: A
Rationale: The most important nursing action when a patient's newborn is neurologically impaired is to assist the patient and her family with the grieving process. This situation can be extremely emotionally challenging for the parents and family as they come to terms with the newborn's condition. Providing support, empathy, and resources for coping with the grief is essential in helping the family navigate this difficult time. By being present, listening, and offering comfort, the nurse can help the family process their emotions and begin to cope with the situation. This support is crucial in promoting the overall well-being of the family as they adjust to the new reality of caring for a neurologically impaired newborn.
You may also like to solve these questions
The nurse is monitoring a pregnant client with severe preeclampsia. Which finding requires immediate intervention?
- A. Blood pressure of 140/90 mmHg.
- B. Urine output of 30 mL/hr.
- C. Complaints of headache and blurred vision.
- D. Weight gain of 1 pound in one week.
Correct Answer: C
Rationale: Headache and blurred vision are signs of worsening preeclampsia, indicating potential eclampsia.
Which order should the nurse implement first?
- A. Give 1L LR IV (VS indicate hypovolemia from dehydration,
- B. LR will reestablish vascular volume and bring BP up)
- C. Weigh the client
- D. Administer Maalox orally
Correct Answer: A
Rationale: The correct order of implementation in this scenario should focus on addressing the immediate physiological needs of the patient. The vital signs indicating hypovolemia from dehydration require prompt action to stabilize the patient's condition. Giving 1L of LR IV will help reestablish vascular volume, improve blood pressure, and address the underlying issue of dehydration. By addressing the hypovolemia first, the nurse can effectively start the process of stabilizing the patient before moving on to other interventions such as weighing the client, administering Maalox orally, or encouraging liquid intake.
A patient has just been prescribed birth control pills and asks about possible side effects. Which of the following should be discussed with the patient?
- A. Increase in menstrual flow
- B. Headaches or nausea
- C. Decrease in libido
- D. Increased risk of breast cancer
Correct Answer: B
Rationale: Headaches and nausea are common side effects of oral contraceptives. Choice A is incorrect because birth control pills typically decrease the menstrual flow. Choice C is not commonly reported with oral contraceptives, and many women report no change in libido. Choice D is incorrect because while oral contraceptives may slightly increase the risk of certain cancers, breast cancer risk is not significantly elevated compared to the general population.
A nurse in the labor and delivery unit is caring for a client who is undergoing external fetal monitoring. The nurse observes that the fetal heart rate begins to slow after the start of a contraction and the lowest rate occurs after the peak of the contraction. Which of the following actions should the nurse take first?
- A. Place the client in the lateral position.
- B. Increase the rate of maintenance IV infusion.
- C. Elevate the client's legs.
Correct Answer: A
Rationale: The priority action for a nurse to take when observing a slowing of the fetal heart rate after the start of a contraction, with the lowest rate occurring after the peak of the contraction, is to place the client in the lateral position. This position, specifically the left lateral position, can alleviate pressure on the vena cava, improve blood flow to the placenta, and help optimize fetal oxygenation. By changing the client's position, the nurse can potentially relieve the decelerations seen in the fetal heart rate and promote better oxygenation for the fetus. This intervention is effective and can be quickly implemented in a labor and delivery setting to support fetal well-being.
When the nurse is assisting a person desiring contraception, a history and physical is done. What is an important question the nurse should ask?
- A. What is your education level?
- B. Have you ever been pregnant?
- C. Are you married?
- D. What is your exercise routine?
Correct Answer: B
Rationale: When assisting a person desiring contraception, asking whether they have ever been pregnant is an important question because it helps the healthcare provider assess the individual's past reproductive history, including any pregnancies and potential complications. This information is important in determining the most suitable contraceptive options for the person, taking into account their previous experiences with pregnancy and childbirth. It can also help in evaluating the effectiveness of their past contraceptive methods and guide the selection of appropriate contraceptive counseling and options.