Nokea
Which of the following actions is appropriate for the nurse to take regarding a 9-year-old girl diagnosed with gonorrhea?
- A. Notify the physician so the child can be admitted to the hospital.
- B. Discuss with the girl the need to stop future sexual encounters.
- C. Question the mother about her daughter's menstrual history.
- D. Report the girl's medical findings to child protective services.
Correct Answer: D
Rationale: Gonorrhea in a 9-year-old girl is highly suggestive of sexual abuse, which requires reporting to child protective services.
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When teaching a parenting class on childhood discipline, the nurse is asked by a parent, 'How long do I place my child in time-out?' How should the nurse best respond?
- A. Use the amount of time it takes to elicit a behavior change.
- B. Use 1 minute per year of age, but do not exceed 5 minutes.
- C. Use as much time as is needed to control the behavior.
- D. Use 1 minute per year of the child's age as needed.
Correct Answer: B
Rationale: When using time-out, use 1 minute per year of the child's age (a 3-year-old would have time-out for 3 minutes). Do not exceed 5 minutes.
A client at 34 weeks' gestation is diagnosed with polyhydramnios. What complication should the nurse monitor for?
- A. Preterm labor.
- B. Placental abruption.
- C. Fetal growth restriction.
- D. Cord prolapse.
Correct Answer: A
Rationale: Polyhydramnios increases the risk of preterm labor due to uterine overdistension.
Why is it important for nurses to approach the topic of sexual history with sensitivity and create a nonjudgmental and confidential environment?
- A. to increase patient satisfaction with the health-care provider
- B. to ensure that patients feel comfortable and supported during the assessment
- C. to promote healthy sexual behaviors among patients
- D. to comply with health-care regulations and standards
Correct Answer: B
Rationale:
Which assessment finding indicates a complication in a client attempting a VBAC?
- A. Complaint of pain between the scapula (could be uterine
- C. Contraction every 3 minutes lasting 70 seconds
- D. Pain level 6 at acme of
Correct Answer: C
Rationale: A client attempting a Vaginal Birth After Cesarean (VBAC) is at higher risk for uterine rupture. A concerning assessment finding in this scenario would be the occurrence of contractions every 3 minutes that are lasting 70 seconds. This pattern of contractions could potentially indicate uterine hyperstimulation, which increases the risk of uterine rupture. It is essential to closely monitor these contractions and address any signs of distress or complications promptly to ensure the safety of both the mother and the baby.
The nurse knows that the emancipated minor is considered to have the legal capacity of an adult and may make his or her own health care decisions. Which child would potentially be considered an emancipated minor?
- A. A minor with financial independence who is living with his parents
- B. A minor who is pregnant
- C. A child older than 13 years of age who asks for emancipation
- D. A minor who puts his or her medical decisions in writing
Correct Answer: B
Rationale: Emancipation may be considered in any of the following situations, depending on the state's laws: membership in a branch of the armed services, marriage, court-determined emancipation, financial independence and living apart from parents, college attendance, pregnancy, mother younger than 18 years of age, and a runaway.