Nokea
Which order should the nurse implement first?
- A. Give 1L LR IV (VS indicate hypovolemia from dehydration,
- B. LR will reestablish vascular volume and bring BP up)
- C. Weigh the client
- D. Administer Maalox orally
Correct Answer: A
Rationale: The correct order of implementation in this scenario should focus on addressing the immediate physiological needs of the patient. The vital signs indicating hypovolemia from dehydration require prompt action to stabilize the patient's condition. Giving 1L of LR IV will help reestablish vascular volume, improve blood pressure, and address the underlying issue of dehydration. By addressing the hypovolemia first, the nurse can effectively start the process of stabilizing the patient before moving on to other interventions such as weighing the client, administering Maalox orally, or encouraging liquid intake.
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When the nurse is assisting a person desiring contraception, a history and physical is done. What is an important question the nurse should ask?
- A. What is your education level?
- B. Have you ever been pregnant?
- C. Are you married?
- D. What is your exercise routine?
Correct Answer: B
Rationale: When assisting a person desiring contraception, asking whether they have ever been pregnant is an important question because it helps the healthcare provider assess the individual's past reproductive history, including any pregnancies and potential complications. This information is important in determining the most suitable contraceptive options for the person, taking into account their previous experiences with pregnancy and childbirth. It can also help in evaluating the effectiveness of their past contraceptive methods and guide the selection of appropriate contraceptive counseling and options.
A patient who is older than 35 years may have difficulty achieving pregnancy because
- A. prepregnancy medical attention is lacking.
- B. personal risk behaviors influence fertility.
- C. contraceptives have been used for an extended period of time.
- D. the ovaries may be affected by the normal aging process.
Correct Answer: D
Rationale: As women age, their ovarian reserve decreases and the quality of their eggs declines, making it more difficult to conceive. This is due to the normal aging process of the ovaries, which can lead to decreased fertility and an increased risk of chromosomal abnormalities in the embryos. Therefore, a patient who is older than 35 years may have difficulty achieving pregnancy because the ovaries may be affected by the normal aging process.
A pregnant woman tells the nurse-midwife, 'I've heard that if I eat certain foods during my pregnancy, the baby will be a boy.' The nurse-midwife should explain that this is a myth, and that the sex of the baby is determined at what time?
- A. At the time of ejaculation
- B. At the time of fertilization
- C. At the time of implantation
- D. At the time of differentiation
Correct Answer: B
Rationale: The sex of a baby is determined at fertilization. Sperm cells carry either an X or Y chromosome, while the ovum only carries an X chromosome. If the sperm contributes an X chromosome, the baby will be female, and if it contributes a Y chromosome, the baby will be male.
The nurse is educating a pregnant client about group B streptococcus (GBS) testing. When is this typically performed?
- A. At the first prenatal visit.
- B. Between 35–37 weeks' gestation.
- C. During the second trimester.
- D. After 40 weeks' gestation.
Correct Answer: B
Rationale: GBS testing is typically performed between 35–37 weeks to identify and manage infection risks during delivery.
A nurse is caring for four newborns. Which of the following newborns should the nurse assess first?
- A. Newborn who has nasal flaring
- B. Newborn who has subconjunctival hemorrhage of the left eye
- C. A newborn who has overlapping suture lines
- D. A newborn who has not rust-stained urine
Correct Answer: A
Rationale: Nasal flaring in a newborn can be a sign of respiratory distress, which is a critical condition that requires immediate attention. It indicates that the newborn is having difficulty breathing and may not be getting enough oxygen. This can be due to various reasons such as lung problems, infections, or other respiratory issues. Therefore, the nurse should assess and address the newborn with nasal flaring first to ensure their breathing is stable and adequate.