Nokea
When instilling erythromycin ointment into the eyes of a neonate 1 hour old, the nurse would explain to the parents that the medication is used to prevent which of the following?
- A. Chorionetinitis from cytomegalovirus.
- B. Blindness secondary to gonorrhea.
- C. Cataracts from beta-hemolytic streptococcus.
- D. Strabismus resulting from neonatal maturation.
Correct Answer: B
Rationale: Erythromycin ointment is used prophylactically to prevent ophthalmia neonatorum, which can lead to blindness due to gonorrhea exposure during delivery.
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When preparing the room for admission of a multigravid client at 36 weeks' gestation diagnosed with severe preeclampsia, which of the following should the nurse obtain?
- A. Oxytocin infusion solution.
- B. Disposable tongue blades.
- C. Portable ultrasound machine.
- D. Padding for the side rails.
Correct Answer: D
Rationale: Padding for the side rails is necessary to prevent injury during potential seizures.
A multigravid client in active labor has been diagnosed with class II heart disease and has had a prosthetic valve replacement. When developing the plan of care for this client, the nurse should anticipate that the physician most likely will order which of the following medications?
- A. Anticoagulants.
- B. Antibiotics.
- C. Diuretics.
- D. Folic acid supplements.
Correct Answer: B
Rationale: Prosthetic heart valves increase the risk of endocarditis during labor due to bacteremia. Prophylactic antibiotics are typically ordered. Anticoagulants may be adjusted, but antibiotics are prioritized during labor.
A primiparous client, 24 hours post-cesarean, reports incisional pain rated 6/10. The nurse should first:
- A. Administer prescribed analgesics.
- B. Encourage deep breathing exercises.
- C. Apply a warm compress to the incision.
- D. Assess the incision for signs of infection.
Correct Answer: A
Rationale: Administering analgesics addresses pain promptly, promoting comfort and mobility.
As the nurse enters the room of a newly admitted primigravid client diagnosed with severe preeclampsia, the client begins to experience a seizure. The nurse should do which in order of priority from first to last?
- A. Call for immediate assistance.
- B. Turn the client to her side.
- C. Note the time when the seizure began.
- D. Maintain airway.
Correct Answer: A,D,B,C
Rationale: Call for help, ensure the airway is clear, turn the client to prevent aspiration, and document the seizure duration.
A client is considering the contraceptive implant. Which of the following side effects should the nurse discuss?
- A. Guaranteed weight loss.
- B. Irregular bleeding and headaches.
- C. Permanent infertility.
- D. Increased risk of ovarian cancer.
Correct Answer: B
Rationale: The contraceptive implant may cause irregular bleeding and headaches, especially initially. It does not guarantee weight loss, cause permanent infertility, or increase ovarian cancer risk.