Nokea
While preparing parents of a 2-day-old,bottle-feeding newborn for discharge the nurse recognizes the parents’ need for additional teaching about formula feeding. Which statement prompted the nurse’s conclusion?
- A. “We plan to clean our baby’s bottles in the dishwasher.”
- B. “Placing the formula in a bowl of warm water will warm it.”
- C. “We will put the bottle of unfinished formula in the refrigerator.”
- D. “Using our city tap water to mix the powdered formula is safe.”
Correct Answer: C
Rationale: Unfinished formula mixed with saliva should be discarded due to bacterial growth risk. Dishwasher cleaning warming in water and municipal tap water use are safe.
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Because the burned child is confined to bed, the nurse assesses for footdrop. Which nursing action best prevents the development of footdrop?
- A. Apply braces to the feet and ankles.
- B. Keep the child in the side-lying position.
- C. Keep sheets tucked in at the foot of the bed.
- D. Rest the child's feet against a footboard.
Correct Answer: D
Rationale: Resting the child's feet against a footboard maintains the feet in a neutral position, preventing plantar flexion and footdrop during prolonged bed rest.
Which information regarding the use of aspirin is best for the nurse to discuss with the client?
- A. Aspirin should be discarded if not used within 2 years of first being opened.
- B. Aspirin can cause a slight ringing in the ears that will go away eventually.
- C. If aspirin alone does not help, take one or two ibuprofen (Advil) along with the aspirin.
- D. It is best to take aspirin with food to prevent GI upset.
Correct Answer: D
Rationale: Taking aspirin with food reduces the risk of gastrointestinal upset, a common side effect, making it a key point for safe use.
The primiparous client,who delivered a term newborn is a lesbian,achieved her pregnancy via artificial insemination and is in a monogamous relationship with a female partner. Which intervention should the nurse add to the newborn’s care plan?
- A. Avoid acknowledging the client’s lesbian relationship.
- B. Encourage the client’s partner to participate in newborn cares.
- C. Ask the partner to leave the room when the newborn is present.
- D. Avoid telling the newborn’s caregivers about the client’s situation.
Correct Answer: B
Rationale: Encouraging the partner to participate in newborn care shows respect and promotes bonding similar to heterosexual partners. Ignoring the relationship or excluding the partner is disrespectful.
During early postburn care of the child, it is essential for the nurse to closely monitor which of the following?
- A. Unburned skin
- B. Bowel elimination
- C. I.V. fluid therapy
- D. Pupillary response to light
Correct Answer: C
Rationale: I.V. fluid therapy is critical in the early postburn phase to prevent hypovolemic shock and maintain organ perfusion. Close monitoring ensures adequate resuscitation and prevents complications like over- or under-hydration.
A primipara presents one week after delivery. She is tearful,has spells of cry and lack of appetite and sleep. What is the most likely diagnosis:
- A. Anaemia.
- B. Post-natal depression.
- C. Schizophrenia.
- D. Maniac disorders.
- E. High grade fever.
Correct Answer: B
Rationale: Post-natal depression is common in the first weeks postpartum presenting with tearfulness appetite loss and sleep disturbances. Other diagnoses are less likely without specific symptoms.