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Which action should the nurse include in the plan?
- A. Minimize noise in the newborn's environment.
- B. Swaddle the newborn loosely to allow free movement.
- C. Position the newborn supine with legs extended.
- D. Encourage frequent handling and stimulation.
Correct Answer: A
Rationale: The correct answer is A because minimizing noise in the newborn's environment is crucial for promoting rest and reducing stress. Newborns are highly sensitive to loud noises, which can disrupt their sleep and affect their overall well-being. By creating a quiet environment, the nurse helps the newborn to feel secure and comfortable, promoting better sleep and overall development.
Choice B is incorrect because swaddling the newborn loosely may pose a suffocation risk and restrict movement, which is not recommended. Choice C is incorrect as positioning the newborn supine with legs extended may increase the risk of sudden infant death syndrome (SIDS). Choice D is also incorrect as encouraging frequent handling and stimulation can overwhelm the newborn's developing nervous system and lead to increased stress.
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Identify the sequence of steps the nurse should take?
- A. Close all nearby windows and doors
- B. Transport the client to another area of the nursing unit
- C. Use the unit's fire extinguisher to attempt to put out the fire
- D. Activate the facility's fire alarm system
Correct Answer: D
Rationale: The correct answer is D: Activate the facility's fire alarm system. This is the first step the nurse should take in case of a fire emergency to ensure the safety of all individuals in the facility. Activating the fire alarm alerts everyone in the building about the fire and prompts an immediate response from the fire department. Closing windows and doors (A) may help contain the fire but should not be the initial action. Transporting the client (B) could put them at risk and is not a priority. Using the fire extinguisher (C) should only be done if safe and appropriate, but activating the alarm is more crucial.
After the nurse indicates chest pain protocol, which of the following is the priority diagnostic test?
- A. PT and INR
- B. 12 lead ECG
- C. Chest X-ray
- D. D-dimer test
Correct Answer: C
Rationale: The correct answer is C: Chest X-ray. When a patient presents with chest pain, a chest X-ray is crucial to evaluate for any acute cardiopulmonary conditions like pneumonia, pneumothorax, or aortic dissection. It helps identify any immediate life-threatening issues that require prompt intervention. PT and INR (A) are coagulation tests not typically indicated for acute chest pain. A 12-lead ECG (B) is important but usually done after the chest X-ray to assess for cardiac abnormalities. D-dimer test (D) is used to rule out pulmonary embolism, but it is not the priority test in the initial evaluation of chest pain.
Which of the following actions should the nurse plan to take?
- A. Apply a cold compress to the site.
- B. Elevate the affected arm above heart level.
- C. Place a warm, moist compress on the site.
- D. Massage the area to reduce inflammation.
Correct Answer: B
Rationale: The correct answer is B: Elevate the affected arm above heart level. Elevating the affected arm helps reduce swelling and promote circulation, aiding in the healing process. By elevating the arm above heart level, the nurse can assist in reducing inflammation and preventing further complications. Applying a cold compress (choice A) can be helpful for acute injuries, but it may not be the most appropriate initial action. Placing a warm, moist compress (choice C) can potentially worsen swelling in this case. Massaging the area (choice D) could aggravate the injury and increase inflammation.
Which finding should the nurse expect?
- A. Spotting
- B. Painless, bright red vaginal bleeding
- C. Soft, relaxed, and non-tender uterus
- D. Fundal height greater than expected for gestational age
- E. Fetal heart rate within normal limits unless significant blood loss occurs
Correct Answer: B
Rationale: The correct answer is B: Painless, bright red vaginal bleeding. This finding is indicative of placenta previa, a condition where the placenta partially or completely covers the cervix. The bright red color indicates fresh bleeding. Spotting (choice A) is more commonly associated with implantation bleeding in early pregnancy. A soft, relaxed, and non-tender uterus (choice C) is not specific to any particular condition. A fundal height greater than expected for gestational age (choice D) could indicate fetal macrosomia or polyhydramnios, but it is not related to the scenario described. While fetal heart rate within normal limits (choice E) is important, it is not the most relevant finding in this case.
Which laboratory test should the nurse report?
- A. INR
- B. Prothrombin time (PT)
- C. Activated partial thromboplastin time (aPTT)
- D. Platelet count
- E. Hemoglobin and hematocrit levels
Correct Answer: A
Rationale: The correct answer is A: INR. The nurse should report the INR (International Normalized Ratio) test because it specifically measures the effectiveness of anticoagulant therapy like warfarin. A high INR indicates a higher risk of bleeding, while a low INR indicates a higher risk of clotting. Reporting the INR can help healthcare providers adjust medication dosage to maintain optimal therapeutic levels.
Incorrect choices:
B: Prothrombin time (PT) is related to INR but is less specific for monitoring anticoagulant therapy.
C: Activated partial thromboplastin time (aPTT) is used to monitor heparin therapy, not warfarin.
D: Platelet count assesses the number of platelets, not the effectiveness of anticoagulant therapy.
E: Hemoglobin and hematocrit levels assess blood volume and oxygen-carrying capacity, not anticoagulant therapy.