Nokea
Which nursing diagnoses may apply to the childbearing family with special needs? (Select all that apply.)
- A. Risk for spiritual distress
- B. Risk for injury
- C. Readiness for enhanced nutrition
- D. Ineffective breathing pattern
Correct Answer: B
Rationale: The correct answer is B: Risk for injury. This is because families with special needs in childbearing may face unique challenges leading to potential risks of injury, such as physical limitations or difficulties in providing adequate care. Option A is incorrect as spiritual distress is not directly related to physical safety. Option C is incorrect as enhanced nutrition readiness does not directly address safety concerns. Option D is incorrect as ineffective breathing pattern is a specific health issue not necessarily related to the family's safety. Therefore, B is the most appropriate nursing diagnosis for addressing safety concerns in the childbearing family with special needs.
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The nurse is monitoring a client with severe preeclampsia. What finding requires immediate intervention?
- A. Proteinuria of +1.
- B. Respiratory rate of 16 breaths per minute.
- C. Deep tendon reflexes +4.
- D. Urine output of 50 mL/hour.
Correct Answer: C
Rationale: The correct answer is C: Deep tendon reflexes +4. In severe preeclampsia, increased reflexes indicate possible progression to eclampsia with seizures. Immediate intervention is needed to prevent seizures. Choice A is not urgent unless higher proteinuria levels are present. Choice B is within normal range. Choice D is concerning but not as urgent as managing potential seizures.
The nurse is caring for a client in labor with a history of cesarean delivery. What is a priority assessment?
- A. Assess for signs of uterine rupture.
- B. Monitor maternal temperature hourly.
- C. Check for signs of preeclampsia.
- D. Assess for excessive fetal movement.
Correct Answer: A
Rationale: The correct answer is A: Assess for signs of uterine rupture. This is the priority assessment because a history of cesarean delivery puts the client at higher risk for uterine rupture during labor. Signs of uterine rupture include severe abdominal pain, abnormal fetal heart rate patterns, and vaginal bleeding. Early detection and intervention are crucial for the safety of both the mother and the baby. Monitoring maternal temperature (B) is important but not as critical as assessing for uterine rupture. Checking for signs of preeclampsia (C) is also important but not a priority in this specific scenario. Assessing for excessive fetal movement (D) is not a priority assessment in this case.
What is the best nursing action for a newborn experiencing hypothermia?
- A. Place the newborn in skin-to-skin contact with the mother
- B. Provide a warm blanket and monitor temperature
- C. Administer IV fluids to stabilize temperature
- D. Monitor glucose levels for hypoglycemia
Correct Answer: A
Rationale: The correct answer is A: Place the newborn in skin-to-skin contact with the mother. This is the best nursing action for a newborn experiencing hypothermia because it provides immediate and effective warmth transfer from the mother to the baby. Skin-to-skin contact helps regulate the newborn's body temperature, promotes bonding, and enhances breastfeeding initiation.
Choice B is incorrect because while providing a warm blanket is important, skin-to-skin contact with the mother is more effective in quickly raising the newborn's temperature. Choice C is incorrect because administering IV fluids is not the first-line treatment for hypothermia in newborns. Choice D is incorrect because monitoring glucose levels for hypoglycemia is important but addressing the hypothermia should take precedence.
Alaska Natives experience higher levels of violence, poverty, and drug and alcohol use, and fewer resources. How can the nurse help these patients?
- A. Tell the patient to stop using substances.
- B. Provide resources that are specific for this population.
- C. Tell the patient to call the police.
- D. Report the abuse to the social worker.
Correct Answer: B
Rationale: The correct answer is B because providing resources specific to Alaska Natives addresses the unique challenges they face. This can include culturally sensitive support services, mental health resources, and community programs. Choice A is incorrect as simply telling the patient to stop using substances is not addressing the underlying issues. Choice C is inappropriate as telling the patient to call the police may not be safe or effective in all situations. Choice D is also incorrect as reporting abuse to a social worker may be necessary but does not directly address the patient's immediate needs for support and resources.
Which of the following should be implemented in is experiencing increased oral mucus should provide management of hypovolemic shock due to postpar- parent education on which of the following? tum hemorrhage? Select all that apply.
- A. Correctly positioning the infant for feedings
- B. IV fluid replacement with 5% dextrose
- C. Initiating cardiopulmonary resuscitation
- D. Administration of oxygen with a nonrebreather
Correct Answer: A
Rationale: The correct answer is A: Correctly positioning the infant for feedings. This is the most appropriate intervention as it addresses the specific issue of increased oral mucus in an infant, which can be a sign of difficulty feeding and potential aspiration. Positioning the infant correctly can help facilitate safe and effective feeding, reducing the risk of complications.
Summary of why other choices are incorrect:
B: IV fluid replacement with 5% dextrose - This choice does not directly address the issue of increased oral mucus and hypovolemic shock due to postpartum hemorrhage.
C: Initiating cardiopulmonary resuscitation - This choice is not indicated for the given scenario and is more appropriate for a life-threatening emergency situation.
D: Administration of oxygen with a nonrebreather - While oxygen may be necessary in certain cases, it does not address the specific issue of increased oral mucus and hypovolemic shock due to postpartum hemorrhage.