Nokea
Which of the following statements by the mother of a neonate diagnosed with bronchopulmonary dysplasia (BPD) indicates effective teaching?
- A. BPD is an acute disease that can be treated with antibiotics.'
- B. My baby may require permanent assisted ventilation.'
- C. Bronchodilators can cure my baby's condition.'
- D. My baby may have seizures later on in life because of this condition.'
Correct Answer: B
Rationale: BPD is a chronic lung condition that may require long-term respiratory support, including permanent assisted ventilation.
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A primiparous client 3 days postpartum is to be discharged on heparin therapy. After teaching her about possible adverse effects of heparin therapy, the nurse determines that the client needs further instruction when she states the adverse effects include which of the following?
- A. Epistaxis.
- B. Bleeding gums.
- C. Slow pulse.
- D. Petechiae.
Correct Answer: C
Rationale: Slow pulse is not a typical adverse effect of heparin; bleeding symptoms like epistaxis, bleeding gums, and petechiae are expected.
A client who had a cesarean delivery 24 hours ago complains of pain from abdominal distention. The client has been on nothing-by-mouth status for the past 36 hours. The nurse should:
- A. Offer the client a carbonated beverage twice daily.
- B. Tell the client to use a straw when drinking fluids.
- C. Limit the client to a soft diet until more bowel sounds exist.
- D. Encourage ambulation in the hallway.
Correct Answer: D
Rationale: Ambulation promotes bowel motility, relieving abdominal distention.
At 32 weeks' gestation, a 15-year-old primigravid client who is 5 feet, 2 inches tall has gained a total of 20 lb, with a 1-lb gain in the last 2 weeks. Urinalysis reveals negative glucose and a trace of protein. The nurse should advise the client that which of the following factors increases her risk for preeclampsia?
- A. Total weight gain.
- B. Short stature.
- C. Adolescent age group.
- D. Proteinuria.
Correct Answer: C
Rationale: Adolescents are at higher risk for preeclampsia due to incomplete physical maturity.
A multigravid client is admitted to the labor area from the emergency room. At the time of admission, the fetal head is crowning, and the client yells, 'The baby's coming!' To help the client remain calm and cooperative during the imminent delivery, which of the following responses by the nurse is most appropriate?
- A. You're right, the baby is coming, so just relax.'
- B. Please don't push because you'll tear your cervix.'
- C. Your doctor will be here as soon as possible.'
- D. I'll explain what's happening to guide you as we go along.'
Correct Answer: D
Rationale: Explaining the process and guiding the client during a precipitous delivery promotes cooperation and reduces anxiety. Telling her to relax is unhelpful, warning against pushing is inaccurate (cervix is fully dilated), and focusing on the doctor's arrival is irrelevant.
The nurse is working on a busy labor and delivery unit with other nurses and a licensed practical nurse. Which of the following labor clients would the nurse assign to the licensed practical nurse?
- A. A G 4, P 3 client with a history of gestational diabetes.
- B. A G 3, P 1, Ab 1 client at 35 weeks' gestation.
- C. A G 1, P 0 client with leaking green amniotic fluid.
- D. A G 2, P 1 client with a history of hyperemesis gravidarum.
Correct Answer: D
Rationale: A G 2, P 1 client with a history of hyperemesis gravidarum is low-risk, suitable for an LPN's scope (e.g., vital signs, basic care). Clients with gestational diabetes, preterm labor (35 weeks), or meconium-stained fluid (G 1, P 0) require RN assessment due to higher risk.