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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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.
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.
What advice should the nurse give if a woman forgets to take a low-dose combination birth control pill?
- A. Take it as soon as she remembers, even if that means taking two pills in one day.
- B. Skip that pill and refrain from intercourse for the remainder of the month.
- C. Wear a pad for the next week because she will experience vaginal bleeding.
- D. Take an at-home pregnancy test at the end of the month to check for a pregnancy.
Correct Answer: A
Rationale: Taking the missed pill promptly minimizes contraceptive failure.
During the assessment of a newborn, it is most important for the nurse to report a:
- A. Temperature of 97.7 degrees Fahrenheit
- B. Pale pink, rust-colored stain in the diaper
- C. Heart rate that drops to 120 beats/min
- D. Breathing pattern that is diaphragmatic with sternal retractions
Correct Answer: D
Rationale: Sternal retractions indicate respiratory difficulty.
To prevent breast engorgement a new breastfeeding mother should be instructed to:
- A. Apply cold packs to the breast before feeding
- B. Breastfeed frequently and for adequate lengths of time to empty the breasts.
- C. Limit her intake of fluids for a few days
- D. Feed her infant no more than every 4 hours
Correct Answer: B
Rationale: Frequent breastfeeding helps prevent engorgement.