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Which treatment is a nursing priority when providing care for an infant diagnosed with bacterial meningitis?
- A. Initiate cardiorespiratory monitoring.
- B. Initiate intravenous fluids.
- C. Observe respiratory isolation.
- D. Administer antibiotic therapy.
Correct Answer: D
Rationale: The first nursing priority is the implementation of antibiotic therapy, which prohibits the microbial damage to the neurologic system through the cerebral spinal fluid. Immediate treatment with antibiotics can prevent serious complications such as death, deafness, reduced cognitive ability, and seizures.
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A client delivered vaginally six hours ago. Which assessment finding can be interpreted as normal?
- A. Temperature 100.0 degrees F
- B. Blood pressure 140/90
- C. Respirations 10
- D. Pulse 90
Correct Answer: A
Rationale: The correct answer is A: Temperature 100.0 degrees F. This finding can be interpreted as normal because a slight increase in body temperature after childbirth is expected due to the physiological changes during labor. A temperature of 100.0 degrees F is within the normal range for postpartum women.
Rationale for why the other choices are incorrect:
B: Blood pressure 140/90 - This blood pressure reading is slightly elevated and may indicate hypertension, which would not be considered normal postpartum.
C: Respirations 10 - A respiratory rate of 10 is abnormally low and could indicate respiratory distress rather than normal postpartum recovery.
D: Pulse 90 - A pulse rate of 90 may be within normal limits, but it is not as indicative of normal postpartum recovery as a slightly elevated temperature would be.
A 17-year-old client delivered her first baby 8 hours ago. Which of the following is an indication that appropriate bonding is occurring? The client:
- A. makes eye contact with the baby.
- B. wonders why the baby cries so much.
- C. asks the nurse to help change the baby's diaper.
- D. asks the nurse if the baby is cute.
Correct Answer: A
Rationale: The correct answer is A: makes eye contact with the baby. This indicates appropriate bonding as eye contact fosters emotional connection and attachment between mother and baby. It shows the mother is engaging with her child, seeking to establish a bond. Choice B suggests lack of understanding of infant communication, choice C indicates practical caregiving rather than emotional bonding, and choice D focuses on the baby's appearance rather than emotional connection.
Which physiological change takes place during the puerperium?
- A. The endometrium begins to undergo alterations necessary for menstruation.
- B. The placenta begins to separate from the uterine wall.
- C. The uterus returns to a pre-pregnant size and location.
- D. The uterus contracts at regular intervals with dilation of the cervix occurring.
Correct Answer: C
Rationale: During the puerperium, the correct physiological change is that the uterus returns to a pre-pregnant size and location (Choice C). This is because after childbirth, the uterus undergoes involution, gradually decreasing in size back to its pre-pregnant state. This process involves the shedding of excess tissue and contraction of uterine muscles. The endometrium (Choice A) does not undergo alterations for menstruation until after the puerperium, as menstruation typically resumes around 6-8 weeks postpartum. The placenta (Choice B) should have been expelled completely during the third stage of labor, so it does not separate during the puerperium. The uterus does contract, but it is not at regular intervals with cervical dilation (Choice D) during the puerperium.
A nurse is caring for a toddler who is in an oxygen tent. Which of the following actions should the nurse take in order to promote comfort while maintaining the child's safety?
- A. Give the child a stuffed animal and car with rubber wheels to play with.
- B. "Give the child a stuffed animal and car with rubber wheels to play with."'
- C. "Change the bedding and the child's clothing frequently or as often as needed."'
- D. "Tuck the bottom of the tent under the mattress on three sides,leaving one side open so the child can look out."'
Correct Answer: C
Rationale: The correct answer is C. Changing the bedding and the child's clothing frequently promotes comfort by ensuring cleanliness and preventing skin irritation. This action also maintains the child's safety by reducing the risk of infections and skin breakdown. Giving a stuffed animal and a car with rubber wheels (Choice A) may pose a choking hazard. Tucking the bottom of the tent under the mattress on three sides (Choice D) may restrict airflow and increase the risk of suffocation.
A child diagnosed with asthma begins corticosteroid treatments. The nurse explains to the parents that the purpose of corticosteroid treatment is to produce which therapeutic effect?
- A. Dilation of bronchial airways
- B. Decrease bronchospasms
- C. Prevention of infection
- D. Anti-inflammatory effect
Correct Answer: D
Rationale: Corticosteroid usage is common for decreasing inflammation of the bronchial airways. While dilation of bronchial airways and decrease in bronchospasms are effects of other medications like albuterol and beta-2 agonists, corticosteroids specifically target inflammation, which is a key component in managing chronic asthma.