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Which explanation is most appropriate when describing physiological jaundice to the parents of a newborn?
- A. The baby has a minor incompatibility of the blood.
- B. The baby is breaking down the extra red blood cells that were present at birth.
- C. The baby is getting too much breast milk, but this is not dangerous.
- D. The baby may have gotten exposed to hepatitis B during the delivery.
Correct Answer: B
Rationale: The correct answer is B: The baby is breaking down the extra red blood cells that were present at birth. Physiological jaundice in newborns occurs due to the breakdown of excess red blood cells, leading to an increase in bilirubin levels. This is a normal process as the baby's liver is still maturing.
Choice A is incorrect because minor blood incompatibility usually leads to a condition known as hemolytic disease of the newborn, not physiological jaundice. Choice C is incorrect as breast milk does not cause physiological jaundice. Choice D is incorrect because hepatitis B exposure does not directly cause physiological jaundice in newborns.
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A nurse is caring for a client and her partner who have experienced a fetal death. Which of the following actions should the nurse take?
- A. Take photos of the newborn to give to the parents.
- B. Tell the parents that they can consider organ donations.
- C. Encourage the parents to avoid allowing older children to visit them in the hospital.
- D. Explain to the parents the need to name the newborn.
Correct Answer: A
Rationale: The correct answer is A because taking photos of the newborn allows the parents to create lasting memories and helps in the grieving process. It also validates the existence of the baby as a member of the family. Choice B may be insensitive as it might be too soon to discuss organ donation. Choice C may isolate the parents from their support system. Choice D may pressure the parents at a difficult time.
A nurse is caring for a 7-month-old infant with acute bronchiolitis. The infant has a persistent, dry, hacking cough that worsens at night, tachypnea, and weakness. Which of the following actions should the nurse implement?
- A. Administer prescribed cough suppressants as needed.
- B. Place the child on droplet precautions.
- C. Administer antibiotics and corticosteroids as prescribed.
- D. Provide intravenous fluids as prescribed.
Correct Answer: D
Rationale: IV fluids ensure hydration and dilute secretions, which is crucial in bronchiolitis.
Which assessment finding suggests thrombophlebitis in a postpartum client?
- A. These signs and symptoms are indications of pulmonary embolism.
- B. These signs and symptoms do not relate to thrombophlebitis. Dyspnea, tachypnea, and apprehension
- C. Chills, hypotension, and abdominal tenderness
- D. Positive Homan's sign, calf warmth, and pain
Correct Answer: D
Rationale: The correct answer is D because a positive Homan's sign, calf warmth, and pain are classic signs of thrombophlebitis in a postpartum client. A positive Homan's sign indicates pain in the calf upon dorsiflexion of the foot, which can indicate a blood clot in the leg veins. Calf warmth and pain are also indicative of a possible deep vein thrombosis.
Choices A and B are incorrect because they relate to pulmonary embolism, not thrombophlebitis. Choice C describes signs of sepsis or intra-abdominal pathology, not specifically thrombophlebitis.
In summary, the key indicators of thrombophlebitis in a postpartum client are a positive Homan's sign, calf warmth, and pain, making choice D the correct answer.
A client in active labor receives a regional anesthetic. Which is the main purpose of regional anesthetics?
- A. To relieve pain by decreasing the client's level of consciousness
- B. To provide general loss of sensation by blocking sensory nerves to an area
- C. To provide pain relief by blocking descending impulses from the central nervous system
- D. To relieve pain by decreasing the perception of pain leading to the pain centers in the brain
Correct Answer: B
Rationale: The correct answer is B: To provide general loss of sensation by blocking sensory nerves to an area. Regional anesthetics work by blocking specific nerve pathways in a targeted area, leading to loss of sensation while maintaining consciousness. This is ideal for laboring clients as it allows pain relief without affecting consciousness or motor function. Choice A is incorrect as regional anesthetics do not aim to decrease consciousness. Choice C is incorrect as regional anesthetics block sensory nerves locally, not descending impulses. Choice D is incorrect as the goal is to block sensation locally, not perception in the brain.
Which of the following are probable signs, strongly indicating pregnancy?
- A. The presence of fetal heart sounds is a positive sign of pregnancy; quickening is a presumptive sign of pregnancy.
- B. These are presumptive signs. They may indicate pregnancy or they may be caused by other conditions, such as disease processes.
- C. Hegar’s sign is a softening of the lower uterine segment, and Chadwick's sign is the bluish or purplish color of the cervix as a result of the increased blood supply and increased estrogen. Ballottement occurs when the cervix is tapped by an examiner's finger and the fetus floats upward in the amniotic fluid and then falls downward.
- D. These are presumptive signs that might indicate pregnancy, but they might be caused by other conditions, such as disease processes.
Correct Answer: C
Rationale: The correct answer is C because Hegar's sign and Chadwick's sign are considered probable signs of pregnancy. Hegar's sign indicates softening of the lower uterine segment, a physiological change that typically occurs in pregnancy. Chadwick's sign refers to the bluish or purplish color of the cervix due to increased blood supply and estrogen levels in pregnancy. These signs are more specific to pregnancy compared to presumptive signs like quickening, which can be caused by other conditions. Ballottement is a technique used to assess fetal movement and position, not a sign indicating pregnancy certainty. Therefore, choices A, B, and D are incorrect as they refer to presumptive signs or signs that could be caused by conditions other than pregnancy.