Nokea
Which is the most important assessment for the nurse to conduct following the administration of epidural anesthesia to a client who is at 40-weeks gestation?
- A. Variability of fetal heart rate.
- B. Station of presenting part.
- C. Level of pain sensation.
- D. Maternal blood pressure.
Correct Answer: D
Rationale: Monitoring maternal blood pressure detects hypotension from epidural-induced vasodilation, preventing reduced placental perfusion.
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Based on the assessment findings, the priority diagnosis suspected is... This diagnosis places the client at risk of...
- A. Mastitis
- B. Engorgement
- C. Blocked milk duct
- D. Inflammatory breast cancer
- E. Abscess
- F. Breastfeeding intolerance
- G. Nipple thrush
Correct Answer: A
Rationale: Mastitis, indicated by fever, localized breast symptoms, and systemic signs, is the priority diagnosis. It risks progressing to an abscess if untreated, requiring prompt intervention.
A father watching the admission of his newborn to the nursery notices that eye ointment is placed in the infant's eyes. He asks the nurse what is the purpose of the ointment. Which response by the nurse will best explain the purpose for administering the ointment?
- A. The ointment will prevent a herpes infection.'
- B. The ointment will clear the infant's vision.'
- C. The ointment will dilate the pupil so the red reflex can be visualized.'
- D. The ointment will prevent eye infections.'
Correct Answer: D
Rationale: Erythromycin ointment prevents ophthalmia neonatorum from gonorrhea or chlamydia, reducing blindness risk.
The nurse is caring for a primigravida client who delivered vaginally 48-hours ago. The client's laboratory results are: hemoglobin 12.5 g/dL (125 g/L), hematocrit 34% (0.34 volume fraction), hepatitis B surface antigen negative, rubella non-immune, group B Streptococcus positive. Which prescription should the nurse prepare to administer?
- A. Hepatitis B immunoglobulin.
- B. Rubella vaccination.
- C. Blood transfusion.
- D. Penicillin G potassium.
Correct Answer: B
Rationale: The client's rubella non-immune status requires postpartum vaccination to prevent future congenital defects. Normal hemoglobin/hematocrit, negative hepatitis B, and post-delivery GBS status do not warrant other interventions.
History and Physical
Nurses Notes
The client is a 4-year-old male with a history of prematurity, short gut syndrome, and liver and bowel transplant. He has been hospitalized for the past 8 months, 6 of those were spent in the pediatric intensive care unit. He is currently in the pediatric unit for observation as his post transplant medications are stabilized for discharge.
Which action(s) is/are appropriate for the nurse caring for this child? Select all that apply.
- A. Avoid mentioning anything about the mother to the child.
- B. Develop a trusting relationship with the child.
- C. Notify the mother that social services will be notified if she does not visit regularly.
- D. Have the child sign a treatment contract stating he will participate in therapy.
- E. Ask the mother to bring a familiar object from home.
- F. Facilitate phone conversations between the child and his mother.
Correct Answer: B,E,F
Rationale: Building trust, providing familiar objects, and facilitating mother-child communication support the child's emotional well-being during hospitalization.
The mother of a 4-month-old baby girl asks the nurse when should she introduce solid foods to her infant. The mother states, 'My mother says I should put rice cereal in the baby's bottle now.' The nurse should instruct the mother to introduce solid foods when her child exhibits which behavior?
- A. Stops rooting when hungry.
- B. Awakens once for nighttime feedings.
- C. Gives up a bottle for a cup.
- D. Opens mouth when food comes her way.
Correct Answer: D
Rationale: Opening the mouth for food, along with head control and sitting support, indicates readiness for solids around 4-6 months.