Nokea
Which of the ff. nursing actions prepares a patient for a lumbar puncture?
- A. Administering enemas until clear
- B. Positioning the patient on his or her side
- C. Removing all metal jewelry
- D. Removing the patient's dentures
Correct Answer: B
Rationale: Positioning the patient on their side is a critical nursing action that prepares a patient for a lumbar puncture. This position is usually used during the procedure to allow easier access to the lumbar region. Placing the patient on their side helps provide better visualization of the spinal landmarks and facilitates the correct positioning of the needle for the lumbar puncture. This position also helps minimize the risk of complications and ensures the safety and comfort of the patient during the procedure. Administering enemas until clear, removing all metal jewelry, and removing the patient's dentures are not specifically associated with preparing a patient for a lumbar puncture.
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A client with group AB blood whose husband has group O has just given birth. The major sign of ABO blood incompatibility in the neonate is which complication or test result?
- A. Negative Coombs test
- B. Bleeding from the nose and ear
- C. Jaundice after the first 24 hours of life
- D. Jaundice within the first 24 hours of life
Correct Answer: D
Rationale: A neonate born to a mother with blood type AB and a father with blood type O is at risk for ABO blood incompatibility, particularly if the neonate is blood type A or B. The major sign of ABO blood incompatibility in the neonate is the development of jaundice within the first 24 hours of life. This occurs due to the mismatch in blood types between the mother and the neonate, leading to the destruction of the neonate's red blood cells. This destruction releases bilirubin, causing jaundice. It is important to note that unlike Rh incompatibility, ABO incompatibility usually does not lead to severe complications requiring treatment. A positive Coombs test result is not typically seen in ABO blood incompatibility.
Parents of a newborn are concerned because the infant's eyes often "look crossed" when the infant is looking at an object. The nurse's response is that this is normal based on the knowledge that binocularity is normally present by what age?
- A. 1 month
- B. 3 to 4 months
- C. 6 to 8 months
- D. 12 months
Correct Answer: C
Rationale: Binocularity refers to the ability of both eyes to focus on the same object and create a single, three-dimensional image. In infants, binocularity typically develops between the ages of 6 to 8 months. Prior to this age, it is common for infants to show occasional misalignment or "crossed" eyes when focusing on an object. This is usually a normal part of the visual development process and tends to resolve as binocular vision strengthens with age. Therefore, it is considered normal for newborns to show occasional crossed eyes until binocularity develops around 6 to 8 months of age.
Which of the following blood types would the nurse identify as the rarest?
- A. A
- B. AB
- C. B
- D. O
Correct Answer: B
Rationale: Blood type AB is the rarest of all the blood types. This is because individuals with AB blood type have both A and B antigens on their red blood cells, making it less common than other blood types. In the ABO blood group system, the distribution of blood types in the general population is approximately 45% type O, 40% type A, 11% type B, and only about 4% type AB. Therefore, blood type AB would be identified as the rarest in the given options.
The nurse observes that a new mother avoids making eye contact with her newborn. The nurse should perform which action?
- A. Examine newborn's eyes for ability to focus.
- B. Assess for other attachment behaviors.
- C. Recognize this as a common reaction in new mothers.
- D. Ask mother why she won't look at newborn.
Correct Answer: B
Rationale: The nurse should assess for other attachment behaviors when a new mother avoids making eye contact with her newborn. This behavior may indicate difficulty forming an emotional bond with the newborn, which can impact the mother-infant relationship. By assessing for other attachment behaviors, the nurse can gather more information to understand the mother's response and provide appropriate support and interventions. Simply recognizing this as a common reaction or asking the mother why she won't look at the newborn may not address the underlying attachment issues that may be present. Examining the newborn's eyes for ability to focus is not relevant in this situation and does not address the mother's behavior.
A client hyperparathyroidism declines surgery and is to receive hormone replacement therapy with estrogen and progesterone. Which of the following instructions would be most important to include in the client's teaching plan?
- A. maintain a moderate exercise
- B. Lose weight
- C. Jog at least 2 miles per day
- D. Rest as much as possible
Correct Answer: A
Rationale: The most important instruction to include in the client's teaching plan would be to maintain a moderate exercise routine (Option A). Regular physical activity is important for overall health, including helping to maintain bone health and strength. This is particularly crucial for individuals with hyperparathyroidism who are declining surgery and opting for hormone replacement therapy, as exercise can help to support bone density and reduce the risk of fractures. However, it is essential to emphasize that the exercise should be moderate and appropriate for the individual's current fitness level, as excessive exercise can have negative effects on bone health in this population.