Nokea
The newborn's mother is concerned about the shape of the baby's head after delivery. She states that the baby looks like a "cone head." What is the most appropriate response by the nurse?
- A. "You don't need to worry about it. It is perfectly normal after birth."
- B. "It is molding caused by the pressure during birth and will disappear in a few days."
- C. "I will report it to the physician and recommend a diagnostic scan."
- D. "It is a collection of blood related to the trauma of delivery and will absorb in a few weeks.
Correct Answer: B
Rationale: "It is molding caused by the pressure during birth and will disappear in a few days."
You may also like to solve these questions
What is the initial action for a mother experiencing severe vaginal bleeding during labor?
- A. Monitor vital signs and provide IV fluids
- B. Position the mother on her left side
- C. Administer oxygen at 10L/min via mask
- D. Prepare for an immediate cesarean section
Correct Answer: C
Rationale: Administering oxygen improves maternal and fetal oxygenation during significant bleeding.
What two steps of the CJMM are included in the assessment step of the nursing process?
- A. noticing cues and evaluating outcomes
- B. analyzing cues and generating solutions
- C. noticing and analyzing cues
- D. analyzing cues and taking action
Correct Answer: A
Rationale: In the assessment step of the nursing process, two steps of the CJMM (Clinical Judgment Model) that are included are noticing cues and evaluating outcomes. Noticing cues involves observing and recognizing relevant information or data related to the patient's health status, while evaluating outcomes involves assessing the effectiveness of the nursing interventions and patient responses to the care provided. By noticing cues, nurses gather information that guides their decision-making process, and by evaluating outcomes, they determine the impact of their actions on the patient's health and adjust the plan of care as needed. These two steps are essential in the assessment phase as they contribute to developing a comprehensive understanding of the patient's needs and progress towards achieving desired health outcomes.
A nurse is planning care for a client who is pregnant and has HIV. Which of the following actions should the nurse include in the plan of care?
- A. Instruct the client to stop taking the antiretroviral medication at 32 weeks of gestation.
- B. Use a fetal scalp electrode during labor and delivery.
- C. Administer a pneumococcal immunization to the newborn within 4 hr. following birth.
- D. Bathe the newborn before initiating skin-to-skin contact
Correct Answer: C
Rationale: Administering a pneumococcal immunization to the newborn within 4 hours following birth is a crucial action to include in the plan of care for a pregnant client with HIV. Infants born to HIV-positive mothers are at higher risk for infections, including pneumococcal disease. Administering a pneumococcal vaccine shortly after birth helps protect the newborn from this serious infection. It is important to follow established guidelines for immunizations in newborns of HIV-positive mothers to optimize the infant's health outcomes.
A nurse is caring for a client who is in labor. Which of the following nursing actions reflects application of the gate control theory of pain?
- A. Administer prescribed analgesic medication.
- B. Encourage the client to rest between contractions.
- C. Massage the client's back.
- D. Turn the client onto her left side.
Correct Answer: C
Rationale: The gate control theory of pain proposes that non-painful input can close the "gates" to painful input, which helps to control and reduce pain perception. Massage, such as massaging the client's back, is a non-pharmacological intervention that can help close the gates and reduce the perception of pain. By massaging the client's back, the nurse is applying this theory to help manage the client's labor pain. Administering analgesic medication (Choice A) is a pharmacological intervention and not specifically related to the gate control theory. Choices B and D are also beneficial nursing actions but do not directly relate to the gate control theory of pain.
What is the most effective form of contraception for a woman who has just given birth and is breastfeeding?
- A. Oral contraceptives
- B. Copper IUD
- C. Contraceptive injections
- D. Emergency contraception
Correct Answer: B
Rationale: The copper IUD is a highly effective, long-term contraception method that does not interfere with breastfeeding. Choice A is incorrect because oral contraceptives may reduce milk supply, and many types are not recommended during breastfeeding. Choice C is incorrect because contraceptive injections may not be ideal during breastfeeding. Choice D is incorrect because emergency contraception is used only after unprotected sex and is not a long-term solution.