Nokea
While preparing a 10-year-old with a lacerated forehead for suturing, the nurse notices both parents and a 12-year-old sibling at the child's bedside. Which instruction best supports the family's involvement?
- A. While waiting for the healthcare provider, only one visitor may stay with the child.
- B. All of you should leave while the healthcare provider sutures the child's forehead.
- C. It is best if the sibling goes to the waiting room until the suturing is completed.
- D. Please decide who will stay when the healthcare provider begins suturing.
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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A 28-year-old client in active labor complains of cramps in her leg. What intervention should be implemented?
- A. Massage the calf and foot.
- B. Extend the leg and dorsiflex the foot.
- C. Lower the leg off the side of the bed.
- D. Elevate the leg above the heart.
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A newborn's parents tell the nurse that their baby is already trying to walk. How should the nurse respond?
- A. Encourage the parents to report this to the healthcare provider.
- B. Acknowledge the parents' observation.
- C. Schedule the newborn for further neurological testing.
- D. Explain the newborn's normal stepping reflex.
Correct Answer: D
Rationale: When parents report that their newborn is trying to walk, the nurse should understand that newborns exhibit a stepping reflex, which is a normal developmental response. Explaining this reflex to the parents helps them understand that it is a typical behavior seen in newborns rather than true attempts to walk. Encouraging the parents to report this to the healthcare provider (Choice A) may cause unnecessary concern since the stepping reflex is a normal part of newborn development. Acknowledging the parents' observation (Choice B) is a good communication strategy but providing education on the normal reflex is essential. Scheduling the newborn for further neurological testing (Choice C) is not indicated in this scenario as the stepping reflex is a typical finding in newborns.
A primipara has delivered a stillborn fetus at 30 weeks gestation. To assist the parents in the grieving process, which intervention is most important for the nurse to implement?
- A. Provide an opportunity for the parents to hold their infant in privacy.
- B. Assist the couple in completing a request for autopsy.
- C. Encourage the couple to seek family counseling within the next few weeks.
- D. Explain the possible causes of fetal demise.
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A client at 28 weeks gestation calls the antepartum clinic and reports experiencing a small amount of bright red vaginal bleeding without uterine contractions or abdominal pain. What instruction should the LPN/LVN provide?
- A. Come to the clinic today for an ultrasound.
- B. Go immediately to the emergency room.
- C. Lie on your left side for about one hour and see if the bleeding stops.
- D. Bring a urine specimen to the lab tomorrow to determine if you have a urinary tract infection.
Correct Answer: A
Rationale: Bright red vaginal bleeding without pain could indicate placental issues such as previa. An ultrasound is necessary to evaluate the cause. It is important to rule out potential serious conditions like placental previa, which can lead to further complications for both the mother and the fetus. Therefore, prompt evaluation through an ultrasound at the clinic is essential for appropriate management and ensuring the well-being of the client and her baby.
Immediately after birth, a newborn infant is suctioned, dried, and placed under a radiant warmer. The infant has spontaneous respirations, and the nurse assesses an apical heart rate of 80 beats/minute and respirations of 20 breaths/minute. What action should the nurse take next?
- A. Initiate positive pressure ventilation.
- B. Intervene after the one-minute Apgar assessment.
- C. Initiate CPR on the infant.
- D. Assess the infant's blood glucose level.
Correct Answer: A
Rationale: A heart rate below 100 bpm in a newborn indicates bradycardia and requires intervention. Positive pressure ventilation should be initiated to improve oxygenation and help increase the infant's heart rate. This intervention is crucial to support the newborn's transition to extrauterine life and prevent further complications.