Nokea
While caring for a male neonate diagnosed with gastroschisis, the nurse observes that the parents seem hesitant to touch the neonate because of his appearance. The nurse determines the presence of which of the following stages of grief?
- A. Denial.
- B. Shock.
- C. Bargaining.
- D. Anger.
Correct Answer: B
Rationale: The parents' hesitation to touch the neonate suggests shock, as they are likely overwhelmed by the neonate's condition.
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A nurse is teaching a client about the use of spermicides. Which of the following instructions should the nurse include?
- A. Spermicides must be applied at least 1 hour before intercourse.
- B. Spermicides are most effective when used alone.
- C. Spermicides should be used with barrier methods for increased effectiveness.
- D. Spermicides provide long-term contraception for up to 24 hours.
Correct Answer: C
Rationale: Spermicides are most effective when used with barrier methods like condoms or diaphragms, as they increase efficacy. They should be applied 10-30 minutes before intercourse, are less effective alone, and are effective for about 1 hour, not 24 hours.
A primiparous client has just delivered a healthy male infant. The client and her husband are Muslim and the husband begins chanting a song in Arabic while holding the neonate. The nurse interprets the father's actions as indicative of which of the following?
- A. Thanking Allah for giving him a male heir.
- B. Singing to his son from the Koran in praise of Allah.
- C. Expressing appreciation that his wife and son are healthy.
- D. Performing a ritual similar to baptism in other religions.
Correct Answer: D
Rationale: The chanting is likely the Adhan, a Muslim ritual where the call to prayer is recited to the newborn, similar to a baptismal rite.
Which of the following would be most important for the nurse to encourage in a primiparous client diagnosed with endometritis who is receiving intravenous antibiotic therapy?
- A. Ambulate to the bathroom frequently.
- B. Discontinue breast-feeding temporarily.
- C. Maintain bed rest in Fowler's position.
- D. Restrict visitors to prevent contamination.
Correct Answer: C
Rationale: Fowler's position promotes drainage of uterine secretions, aiding recovery from endometritis.
Commercial formulas contain 20 calories per ounce. A 1-day-old infant's weight in the morning was 8 lb and he was fed 45 mL at 2 a.m., 5:30 a.m., 8 a.m., 11 a.m., 2 p.m., 4:30 p.m., 8 p.m., and 10:30 p.m. What is the total amount of calories the infant received today?
- A. calories.
Correct Answer: B
Rationale: The infant was fed 45 mL 8 times, totaling 360 mL. Since 1 oz ≈ 30 mL, 360 mL ÷ 30 mL/oz = 12 oz. At 20 calories per ounce, 12 oz × 20 cal/oz = 240 calories.
The nurse is caring for a multiparous client 48 hours after cesarean delivery. Which finding indicates a potential complication?
- A. Clear urine output via catheter.
- B. Incisional pain relieved by medication.
- C. Scant lochia serosa.
- D. Homan's sign negative bilaterally.
Correct Answer: C
Rationale: Scant lochia serosa at 48 hours may indicate retained clots or infection, requiring further assessment.