Nokea
With a breech presentation, the nurse must be particularly alert for which of the following?
- A. quickening
- B. ophthalmia neonatorum
- C. pica
- D. prolapsed umbilical cord
Correct Answer: D
Rationale: Prolapsed umbilical cord is the descent of the umbilical cord into the vagina before the fetal presenting part and compression of the cord between the presenting part and the maternal pelvis, compromising or completely cutting off fetoplacental perfusion. This is an emergency situation; immediate delivery should be attempted to save the fetus.
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A 12-year-old male is brought to his primary care provider to determine whether sexual abuse has occurred. The mother states, 'Because there is no permanent physical damage, he does not need any more treatment.' The nurse's response should be based on which of the following pieces of information?
- A. Male victims of sexual abuse seldom have long-term psychological problems.
- B. Survivors of male sexual abuse might become confused about their sexual identity.
- C. Unless treated, all male sex abuse survivors grow up to abuse other children.
- D. All children who have been sexually abused have the same needs, regardless of gender.
Correct Answer: B
Rationale: Male children are sexually abused nearly as often as female children. Perpetrators are usually men but can be women. Needs of male children who have been sexually abused might be different from the needs of female survivors. Male survivors might respond in anger, question their sexuality, use alcohol and other drugs, and might try to prove their masculinity by performing daring acts.
The nurse is working with families who have been displaced by a fire in an apartment complex. What is the priority intervention during the initial assessment?
- A. Provide a liaison to meet housing needs.
- B. Attentively listen when clients describe their feelings.
- C. Offer nurturing support for clients who are confused by the events.
- D. Provide structure for clients exhibiting moderate to severe anxiety.
Correct Answer: A
Rationale: After physical needs of housing, clothing and food are met, the nurse should focus on assisting clients to manage the psychological effects of loss.
A nurse is performing a screening on a patient that has been casted recently on the left lower extremity. Which of the following statements should the nurse be most concerned about?
- A. The patient reports, 'I didn't keep my extremity elevated like the doctor asked me to.'
- B. The patient reports, 'I have been having pain in my left calf.'
- C. The patient reports, 'My left leg has really been itching.'
- D. The patient reports, 'The arthritis in my wrists is flaring up, when I put weight on my crutches.'
Correct Answer: B
Rationale: Pain may be indicating neurovascular complication.
A woman asks, 'How much alcohol can I safely drink while pregnant?' The nurse's best response is:
- A. The amount of alcohol that is safe during pregnancy is unknown.'
- B. Consuming one or two beers or glasses of wine a day is considered safe for a healthy pregnant woman.'
- C. Drinking three or more drinks on any given occasion is the only harmful type of drinking during pregnancy.'
- D. You can have a drink to help you relax and get to sleep at night.'
Correct Answer: A
Rationale: The amount of alcohol that is safe during pregnancy is unknown. Fetal alcohol syndrome is a combination of mental and physical abnormalities present in infants born to mothers who have consumed alcohol during pregnancy.
An 8-year-old Asian child is being examined during a school screening. The nurse notices small bruises on the anterior and posterior ribs. The nurse should ask the child:
- A. If the family practices coining
- B. Who hit him
- C. If the child has fallen
- D. How long the abuse has been occurring
Correct Answer: A
Rationale: Coining, a cultural practice in some Asian communities, can cause bruising and should be assessed to differentiate from abuse. Other options assume abuse prematurely.