Nokea
Which fetal heart monitor pattern can indicate cord compression?
- A. variable decelerations
- B. early decelerations
- C. bradycardia
- D. tachycardia
Correct Answer: A
Rationale: Variable decelerations are associated with umbilical cord compression, which can intermittently reduce fetal blood flow. The other patterns are related to different fetal conditions. Reduction of Risk Potential
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A 17-year-old female was raped by a young man in her neighborhood. She is in the Emergency Department for evaluation and tests. After the procedure is completed, a rape crisis counselor (nurse specialist) talks to the client in a conference room regarding the rape. Implementing counseling by the nurse specialist for the raped victim represents:
- A. assessment.
- B. crisis intervention.
- C. empathetic concern.
- D. unwarranted intrusion.
Correct Answer: B
Rationale: Counseling by a rape crisis nurse specialist is a form of crisis intervention, providing immediate support to address the trauma. It is not merely assessment, empathy, or intrusion. Coordinated Care
A 4-year-old child with Down syndrome is admitted to the hospital with pneumonia. She has a heart murmur and appears to be in respiratory distress. Her mother asks why her child has a heart murmur. What is the best nursing response?
- A. Because she has pneumonia, her heart is working harder and causes the murmur.'
- B. Heart murmurs come and go in children. It is not a great concern.'
- C. Because of the pneumonia, her ductus arteriosus is functioning again.'
- D. Heart defects are common in children with Down syndrome. Her illness may make the murmur louder.'
Correct Answer: D
Rationale: Congenital heart defects, like ventricular septal defects, are common in Down syndrome, and pneumonia may amplify a murmur due to increased cardiac workload.
A newborn is to receive phototherapy for hyperbilirubinemia. Which nursing action is essential?
- A. Keep the infant NPO for two hours before the treatment.
- B. Ask the mother to stay away from the infant during the treatment.
- C. Monitor the client's pulse rate very carefully.
- D. Cover the baby's eyes during the treatment.
Correct Answer: D
Rationale: Covering the eyes protects the newborn's retinas from phototherapy light, a critical safety measure.
Which of the following injuries, if demonstrated by a client entering the Emergency Department, is the highest priority?
- A. open leg fracture
- B. open head injury
- C. stab wound to the chest
- D. traumatic amputation of a thumb
Correct Answer: C
Rationale: A stab wound to the chest is the highest priority due to potential for pneumothorax or mediastinal shift, which can be life-threatening. The ABC (airway, breathing, circulation) principle prioritizes this injury. Physiological Adaptation
A male patient with thrombophlebitis is apprehensive about the possibility of a clot reaching his heart, causing sudden death.
The nurse's initial intervention should be to:
- A. Clarify his misconception.
- B. Explain preventive measures.
- C. Teach recognition of early symptoms.
- D. Encourage discussion of the patient's concern.
Correct Answer: A
Rationale: Clarifying that thrombophlebitis clots rarely reach the heart addresses the patient's fear directly.