Nokea
Which of the following is the priority nursing action if the child shows symptoms of hypoglycemic reaction?
- A. Give the child orange juice or milk to drink.
- B. Give the child 10% glucose I.V.
- C. Notify the physician immediately.
- D. Administer a second dose of insulin.
Correct Answer: A
Rationale: For hypoglycemia, the priority is to rapidly raise blood glucose. Giving orange juice or milk provides quick-acting carbohydrates, the first-line treatment for conscious patients with mild to moderate hypoglycemia.
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A 23 years old primigravida comes in labour room for induction of labour. Cervix is closed and 3 cm long. Which of the following medicine will be given to her for cervical ripening?
- A. Methergin.
- B. Salbutamol.
- C. Prostaglandin E2.
- D. Paracetamol.
- E. Methyldopa.
Correct Answer: C
Rationale: Prostaglandin E2 is used for cervical ripening in induction of labor as it softens and dilates the cervix. Other medications are not indicated for this purpose.
A 30 years old G5P4 is admitted in labor room with H/O 32 weeks gestation,mild vaginal bleeding and abdominal pain. O/E her blood pressure 140/100 mm Hg abdomen is tense tender and hard. Fetal heart sounds are not audible. What is the most likely diagnosis:
- A. Placenta praevia.
- B. Abruptio placenta.
- C. Preterm labour.
- D. Urinary tract infection.
- E. Vasa praevia.
Correct Answer: B
Rationale: Abruptio placenta presents with vaginal bleeding abdominal pain a tense uterus and fetal distress (absent heart sounds) often with hypertension. Placenta previa typically causes painless bleeding and other options do not match the clinical picture.
The nurse is reviewing the following labor history of a postpartum mother: “Mother positive for group B streptococcal (GBS) infection at 37 weeks’ gestation. Membranes ruptured at home 14 hours before presentation to the hospital at 40 weeks’ gestation. Precipitous labor,no antibiotic given.” Considering this information the nurse should observe her 15-hour-old newborn closely for which finding?
- A. Temperature instability
- B. Pink stains in the diaper
- C. Meconium stools
- D. Presence of erythema toxicum
Correct Answer: A
Rationale: GBS infection risk increases with prolonged membrane rupture and no antibiotics with temperature instability as an early symptom. Pink stains meconium and erythema toxicum are normal.
Which nursing interventions are essential to restore the child's fluid and electrolyte balance during the emergent phase of burn care and treatment? Select all that apply.
- A. Initiate the administration of I.V. fluids.
- B. Track the child's vital signs.
- C. Give the child sips of water.
- D. Encourage the child to consume protein-rich feedings.
- E. Monitor the child's urine output.
- F. Assemble equipment for a small-gauge venous catheter.
Correct Answer: A,B,E,F
Rationale: During the emergent phase, I.V. fluids restore fluid and electrolyte balance due to massive losses. Monitoring vital signs and urine output assesses fluid status, and preparing venous access ensures timely administration. Oral fluids and protein-rich feedings are inappropriate due to gastrointestinal dysfunction.
The nurse is caring for a 30-year-old,single female who delivered a term newborn. What is the best way for the nurse to assess the impact of the newborn on the client’s lifestyle?
- A. Observe how the client interacts with her hospital visitors.
- B. Review the prenatal record for clues about the client’s lifestyle.
- C. Ask the client what plans she has made for newborn care at home.
- D. Observe the relationship between the client and her newborn’s father.
Correct Answer: C
Rationale: Open-ended questions about newborn care plans encourage sharing of lifestyle adjustments especially for single parents. Visitors prenatal records or father involvement are less direct.