Nursing Elites

1. During a teaching session with a client in labor, a nurse is explaining episiotomy. Which of the following information should the nurse include?

• A. An episiotomy is a perineal incision made by the provider to facilitate delivery of the fetus
• B. A fourth-degree episiotomy extends into the rectal area and is not recommended
• C. An episiotomy is an incision made by the provider to facilitate delivery of the fetus
• D. A mediolateral episiotomy is preferred over a median episiotomy for most deliveries

Correct answer: C

Rationale: The correct answer is C because an episiotomy is an intentional incision made by the healthcare provider to widen the vaginal opening during delivery. This procedure is performed to facilitate the birth of the baby and prevent uncontrolled tearing of the perineum. It is important for the nurse to educate the client on the purpose and implications of episiotomy to ensure informed decision-making and proper postpartum care. Choice A is incorrect because an episiotomy is not a perineal tear but a deliberate incision. Choice B is incorrect because a fourth-degree episiotomy extending into the rectal area is not a standard practice and can lead to complications. Choice D is incorrect because a mediolateral episiotomy is not universally considered easier to repair than a median episiotomy; the choice of incision type depends on the healthcare provider's preference and clinical situation.

2. A caregiver is learning about newborn safety. Which of the following statements by a parent indicates an understanding of the teaching?

• A. I will dress my baby in flame-retardant clothing.
• B. I will ensure a bib on my baby at night to keep her clothing dry.
• C. I will warm my baby's formula using the lowest setting in the microwave.
• D. I will cover the crib mattress with plastic to prevent staining.

Correct answer: A

Rationale: The correct answer is A. Dressing a baby in flame-retardant clothing is crucial to prevent injuries, especially in case of accidental exposure to fire sources. This safety measure can provide an added layer of protection for the newborn. The other options do not directly address newborn safety concerns or best practices. Option B focuses on keeping clothing dry, which is not a primary safety concern. Option C poses a risk of overheating the formula, which can be dangerous for the baby. Option D, covering the crib mattress with plastic, may pose a suffocation hazard to the baby.

3. A healthcare provider is reinforcing teaching with a client about a new prescription for medroxyprogesterone. Which of the following information should the provider include in the teaching? (Select all that apply)

• A. Weight fluctuations can occur.
• B. Irregular vaginal spotting can occur.
• C. You should increase your intake of calcium.
• D. All of the above

Correct answer: D

Rationale: When educating a client about medroxyprogesterone, it is important to include information about potential side effects and recommendations. Weight fluctuations and irregular vaginal spotting are common side effects of medroxyprogesterone. Additionally, increasing calcium intake is often advised to counteract the potential bone density loss associated with this medication. Therefore, all the statements provided are correct, making option D the correct answer. Choices A, B, and C are all essential pieces of information that the healthcare provider should convey to the client regarding medroxyprogesterone.

4. When assisting a client with breastfeeding, which of the following reflexes will promote the newborn to latch?

• A. Babinski
• B. Rooting
• C. Moro
• D. Stepping

Correct answer: B

Rationale: The correct answer is B: Rooting. The rooting reflex is crucial in newborns as it helps them locate the nipple for feeding. This reflex involves turning the head towards a stimulus that touches the cheek or mouth, aiding in the process of latching onto the breast for breastfeeding. The Babinski reflex is the fanning out and curling of the toes when the sole of the foot is stroked, the Moro reflex is the startle reflex in response to a sudden noise or movement, and the stepping reflex is the appearance of taking steps when an infant is held upright with feet touching a solid surface. Therefore, choices A, C, and D are incorrect as they do not play a direct role in promoting a newborn to latch during breastfeeding.

5. When caring for a client suspected of having hyperemesis gravidarum, which finding is a manifestation of this condition?

• A. Hgb 12.2 g/dL
• B. Urine ketones present
• C. Alanine aminotransferase 20 IU/L
• D. Blood glucose 114 mg/dL

Correct answer: B

Rationale: The correct answer is B: Urine ketones present. The presence of urine ketones indicates dehydration, which is a common manifestation of hyperemesis gravidarum. Hyperemesis gravidarum is characterized by severe nausea, vomiting, weight loss, and electrolyte imbalances due to dehydration. Monitoring for ketonuria helps assess the degree of dehydration in clients with this condition. Choices A, C, and D are incorrect because hemoglobin level, alanine aminotransferase level, and blood glucose level are not specific manifestations of hyperemesis gravidarum. While these laboratory values may be abnormal in some cases, they are not typically used to diagnose or assess the condition.

Similar Questions