Nokea
Which of the following comments suggest that a client whose baby was born with a congenital defect is in the bargaining phase of grief?
- A. I hate myself. I caused my baby to be sick.
- B. I'll take him to a specialist. Then he will get better.
- C. I can't seem to stop crying.
- D. This can't be happening.
Correct Answer: B
Rationale: Bargaining involves attempting to find solutions.
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What is the nursing intervention for unilateral edema in a lower extremity and a hot, red area on the leg?
- A. Contact the health-care provider.
- B. Explain this is a normal finding.
- C. Massage calf.
- D. Offer pain medication.
Correct Answer: A
Rationale: The correct answer is A: Contact the health-care provider. Unilateral edema along with a hot, red area on the leg can indicate a potential serious condition such as deep vein thrombosis (DVT). It is crucial to involve the healthcare provider immediately for further evaluation and treatment. Contacting the healthcare provider ensures timely diagnosis and appropriate management.
Summary:
B: Explaining this as a normal finding is incorrect as it could be a sign of a serious condition.
C: Massaging the calf can potentially dislodge a clot in case of DVT, leading to severe complications.
D: Offering pain medication without proper evaluation can mask the symptoms and delay necessary medical intervention.
A mother asks the nurse to tell her about the responsiveness of neonates at birth. Which of the following answers is appropriate? Select one that doesn't apply.
- A. Babies have a poorly developed sense of smell until they are 2 months old.
- B. Babies respond to all forms of taste well
- C. but they prefer to eat sweet things like breast milk.
- D. Babies are especially sensitive to being touched and cuddled.
Correct Answer: A
Rationale: Newborns have limited senses initially but can distinguish tastes, enjoy touch, and have limited vision until around 3 months.
A breastfeeding woman calls the pediatric nurse with the following complaint:"I woke up this morning with a terrible cold. I don't want my baby to get sick. Which kind of formula should I have my husband feed the baby until I get better?" Which of the following replies by the nurse is appropriate at this time?
- A. Any formula brand is satisfactory, but it is essential that it be mixed with water that has been boiled for at least 5 minutes.
- B. Don't forget to pump your breasts every 3 hours while the baby is being fed the prescribed formula.
- C. The best way to keep your baby from getting sick is for you to keep breastfeeding him rather than switching him to formula.
- D. In addition to giving the baby formula, you should wear a surgical face mask when you are around him.
Correct Answer: C
Rationale: Breastfeeding provides antibodies to protect the baby.
The nurse assesses the breasts. What is a warning sign?
- A. colostrum expressed
- B. nipple everted
- C. redness, pain, and heat
- D. filling with milk
Correct Answer: C
Rationale: The correct answer is C because redness, pain, and heat are warning signs of a possible breast infection or inflammation, such as mastitis. This indicates an abnormality that requires further assessment and intervention.
A: Colostrum expressed is a normal occurrence during pregnancy or after delivery and is not a warning sign.
B: Nipple everted is also a normal anatomical variation and not a warning sign.
D: Filling with milk is expected during lactation and not necessarily indicative of a problem.
Postpartal overdistention of the bladder and urinary retention can lead to which complication?
- A. Fever and increased blood pressure
- B. Postpartum hemorrhage and eclampsia
- C. Urinary tract infection and uterine rupture
- D. Postpartum hemorrhage and urinary tract infection
Correct Answer: C
Rationale: Rationale: Postpartal overdistention of the bladder and urinary retention can lead to urinary tract infection and uterine rupture. When the bladder is overdistended, it can cause urinary stasis, leading to bacterial growth and increasing the risk of urinary tract infections. Additionally, the pressure from the distended bladder can impede uterine contractions, potentially causing uterine rupture. Fever and increased blood pressure (Choice A) are not direct complications of bladder overdistention. Postpartum hemorrhage and eclampsia (Choice B) are not typically associated with bladder overdistention. Postpartum hemorrhage and urinary tract infection (Choice D) are not as directly related to the complications of bladder overdistention as urinary tract infection and uterine rupture are.