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When teaching a parenting class on childhood discipline, the nurse is asked by a parent, 'How long do I place my child in time-out?' How should the nurse best respond?
- A. Use the amount of time it takes to elicit a behavior change.
- B. Use 1 minute per year of age, but do not exceed 5 minutes.
- C. Use as much time as is needed to control the behavior.
- D. Use 1 minute per year of the child's age as needed.
Correct Answer: B
Rationale: When using time-out, use 1 minute per year of the child's age (a 3-year-old would have time-out for 3 minutes). Do not exceed 5 minutes.
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A nurse is assessing a client who is 8 hr postpartum and multiparous. Which of the following findings should alert the nurse to the client's need to urinate?
- A. Moderate lochia rubra
- B. Fundus three fingerbreadths above the umbilicus
- C. Moderate swelling of the labia
- D. Blood pressure 130/84 mm Hg
Correct Answer: B
Rationale: A fundus three fingerbreadths above the umbilicus indicates that the uterus is not adequately contracting, which can obstruct the flow of urine from the bladder. Postpartum clients often experience urinary retention due to decreased sensation in the bladder, trauma from delivery, and decreased bladder tone. Failure to empty the bladder promptly can lead to urinary retention and potential complications such as urinary tract infections or bladder distention. Therefore, the nurse should be alert to the client's need to urinate when assessing the fundal height.
Why is it important for nurses to approach the topic of sexual history with sensitivity and create a nonjudgmental and confidential environment?
- A. to increase patient satisfaction with the health-care provider
- B. to ensure that patients feel comfortable and supported during the assessment
- C. to promote healthy sexual behaviors among patients
- D. to comply with health-care regulations and standards
Correct Answer: B
Rationale:
The nurse is preparing a handout for female adolescents on the menstrual cycle. What phase of the cycle occurs if fertilization does not take place?
- A. Menstrual
- B. Proliferative
- C. Secretory
- D. Ischemic
Correct Answer: D
Rationale: The ischemic phase of the menstrual cycle occurs when the corpus luteum degenerates in the absence of fertilization. This leads to a decline in progesterone and estrogen levels, resulting in the shedding of the uterine lining during menstruation.
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: Supporting the family through grief is crucial.
The nurse teaches a new mother that neonatal weight loss in the first 3 days of life is most often the result of:
- A. Allergy to formula
- B. a hypoglycemic response
- C. Inadequate breast or formula feeding
- D. Excretion of fluid via lungs, urinary bladder and bowels.
Correct Answer: D
Rationale: Fluid loss is the primary cause of early weight loss.