Nursing Care of the Client with Special Needs Quiz

1. A nurse notes that the 4-hour postpartum client has cool, clammy skin and that she is restless and excessively thirsty. The nurse immediately notifies the registered nurse and then:

Checks the vital signs

Begins fundal message

Encourages ambulation

Encourages the client to drink fluids

Symptoms of hypovolemia include cool, clammy and pale skin, feelings of anxiety and restlessness, and thirst. The nurse would check the vital signs. The nurse would not ambulate the client or encourage fluids until specific orders are given to do so. There is no information in the question to indicate the need for fundal message.

Explanation

Symptoms of hypovolemia include cool, clammy and pale skin, feelings of anxiety and restlessness, and thirst. The nurse would check the vital signs. The nurse would not ambulate the client or encourage fluids until specific orders are given to do so. There is no information in the question to indicate the need for fundal message.

2. A client asks a nurse why her newborn baby needs an injection of Vitamin K. The nurse makes which statement to the client:

Your newborn needs vitamin K to develop immunity

The vitamin K will protect the newborn from becoming jaundiced

Newborns are deficient in vitamin K. This injection prevents your baby from abnormal bleeding.

Newborns have sterile bowels. The vitamin K will colonize the bowel with necessary bacteria.

Vitamin K is necessary for the body to synthesize coagulation factors, and it is administered to the newborn infant to prevent abnormal bleeding. It promotes the liver's formation of clotting factors II, VII, IX, and X. Newborn infants are deficient in vitamin K because the bowel does not have the bacteria necessary for synthesizing this fat soluble vitamin. The normal flora in the intestinal tract produces vitamin K, but the newborn's bowel does not support the normal production of the vitamin until bacteria have adequately colonized it. The bowel becomes colonized by bacteria as food is ingested. Vitamin K does not promote immunity or prevent the infant from becoming jaundiced.

Explanation

Vitamin K is necessary for the body to synthesize coagulation factors, and it is administered to the newborn infant to prevent abnormal bleeding. It promotes the liver's formation of clotting factors II, VII, IX, and X. Newborn infants are deficient in vitamin K because the bowel does not have the bacteria necessary for synthesizing this fat soluble vitamin. The normal flora in the intestinal tract produces vitamin K, but the newborn's bowel does not support the normal production of the vitamin until bacteria have adequately colonized it. The bowel becomes colonized by bacteria as food is ingested. Vitamin K does not promote immunity or prevent the infant from becoming jaundiced.

3. A nurse is assigned to assist with caring for a neonate born to a mother with AIDS. The nurse understands that which of the following should be included in the plan of care?

Monitor the neonate's vital signs routinely

Maintain standard precautions at all times while caring for the neonate

Instruct breast-feeding mothers regarding the treatment of their nipples with an antifungal cream

Initiate a referral to evaluate for blindness, deafness, learning, or behavioral problems in the neonate.

The neonate born to a mother with AIDS must be cared for with strict attention to standard precautions. This prevents the transmission of infection from the neonate if he or she is infected, to others, and it prevents the transmission of other infectious agents to the possibly immunocompromised neonate. A mother with AIDS should not breastfeed. Options 1 and 4 are not specific to the care of a potentially AIDS infected neonate.

Explanation

The neonate born to a mother with AIDS must be cared for with strict attention to standard precautions. This prevents the transmission of infection from the neonate if he or she is infected, to others, and it prevents the transmission of other infectious agents to the possibly immunocompromised neonate. A mother with AIDS should not breastfeed. Options 1 and 4 are not specific to the care of a potentially AIDS infected neonate.

4. A concerned client tells the nurse that her husband, who was so excited about the baby before its birth, is apparently happy but seems to be afraid of caring for the baby. What suggestions should the nurse give the client's husband to help resolve the issue?

Hold the newborn

Speak to his friends

Read up on parental care

Speak to the physician

The nurse should suggest that the father care for the newborn by holding and talking to the child. Reading up on parental care and speaking to his friends or the physician will not help the father resolve his fears about caring for the child. The nurse may also decide to explore with the father if he has unresolved feelings about expectations he before the child was born. In some cases, grief over loss of the "perfect child" may manifest in the parents inability to select a name for the baby.

Explanation

The nurse should suggest that the father care for the newborn by holding and talking to the child. Reading up on parental care and speaking to his friends or the physician will not help the father resolve his fears about caring for the child. The nurse may also decide to explore with the father if he has unresolved feelings about expectations he before the child was born. In some cases, grief over loss of the "perfect child" may manifest in the parents inability to select a name for the baby.

5. A nurse administers erythromycin ointment (0.5%) to the newborn's eyes, and the mother asks the nurse why this is done. The nurse tells the client that this is routinely done to:

Prevent cataracts in the neonate born to a woman who is susceptible to rubella

Protect the neonate's eyes from possible infections acquired while hospitalized

Minimize the spread of microorganisms to the neonate from invasive procedures during delivery

Prevent ophthalmia neonatorum from occurring after delivery to a neonate born to a woman with an untreated gonococcal infection.

Erythromycin ophthalmic ointment 0.5% is used as prophylactic treatment for ophthalmia neonatorum which is caused by the bacteria Neisseria gonorhoeae. The preventive treatment is required by law. Other options are not the purposes of administering this medication.

Explanation

Erythromycin ophthalmic ointment 0.5% is used as prophylactic treatment for ophthalmia neonatorum which is caused by the bacteria Neisseria gonorhoeae. The preventive treatment is required by law. Other options are not the purposes of administering this medication.

6. A male neonate has just been circumcised. The nurse would expect the surgical site to appear:

Pink, without drainage

Reddened, with a small amount of bloody drainage

Reddened with a small amount of yellow exudate on the glans

Reddened with a large amount of bloody drainage that requires a dressing change every 30 minutes.

The glans penis is normally dark red. After circumcision, a small amount of bloody drainage is expected. During the normal healing process, the glans becomes covered with yellow exudate. If excessive bleeding is noted from the circumcision, the nurse applies gentle pressure to the site of bleeding with a sterile gauze pad. If the bleeding is not controlled, the physician is notified, because a blood vessel may need to be ligated.

Explanation

The glans penis is normally dark red. After circumcision, a small amount of bloody drainage is expected. During the normal healing process, the glans becomes covered with yellow exudate. If excessive bleeding is noted from the circumcision, the nurse applies gentle pressure to the site of bleeding with a sterile gauze pad. If the bleeding is not controlled, the physician is notified, because a blood vessel may need to be ligated.

7. A 27-week gestation infant is in the neonatal intensive care unit with respiratory distress. Which nursing intervention is essential for preventing retinopathy of prematurity (ROP)?

Monitor oxygen concentration level

Monitor bilirubin level

Check the hemoglobin level

Check the pupil response

Respiratory distress syndrome is associated with preterm infants and surfactant deficiency. These infants have hypoxia, respiratory acidosis, and metabolic acidosis. Goals of treatment are to maintain adequate oxygenation and correct acidosis. Nursing interventions include monitoring respirations and pulse oximetry at least once per hour. It is especially important to monitor oxygen concentration delivered as prolonged exposure to high concentrations of oxygen contribute to retinopathy of prematurity.

Explanation

Respiratory distress syndrome is associated with preterm infants and surfactant deficiency. These infants have hypoxia, respiratory acidosis, and metabolic acidosis. Goals of treatment are to maintain adequate oxygenation and correct acidosis. Nursing interventions include monitoring respirations and pulse oximetry at least once per hour. It is especially important to monitor oxygen concentration delivered as prolonged exposure to high concentrations of oxygen contribute to retinopathy of prematurity.

8. A nurse is caring for a postpartum client. At 4 hours postpartum, the client's temperature is 102^o F (38.9^oC). The appropriate nursing action would be to:

Apply cool packs to the abdomen

Continue to monitor the temperature

Remove the blanket from the client's bed

Notify the Registered Nurse, who will then contact the physician

During the first 24-hours postpartum, the mother's temperature may be elevated as a result of dehydration. However, of the temperature is more than 2oF above normal, this may indicated infection, and the physician will need to be notified.

Explanation

During the first 24-hours postpartum, the mother's temperature may be elevated as a result of dehydration. However, of the temperature is more than 2oF above normal, this may indicated infection, and the physician will need to be notified.

9. Preterm newborns are at risk for developing respiratory distress syndrome (RDS) The nurse monitors for clinical signs associated with RDS, knowing that these signs include:

Tachypnea and retractions

Acrocyanosis and grunting

Hypotension and bradycardia

The presence of a barrel chest with acrocyanosis

The newborn infant with RDS may present with clinical signs of cyanosis, tachypnea, apnea, nasal flaring, chest wall retractions, or audible grunts. Acrocyanosis is a bluish discoloration of the hands and feet that is associated with immature peripheral circulation and can occur during the first few hours of life.

Explanation

The newborn infant with RDS may present with clinical signs of cyanosis, tachypnea, apnea, nasal flaring, chest wall retractions, or audible grunts. Acrocyanosis is a bluish discoloration of the hands and feet that is associated with immature peripheral circulation and can occur during the first few hours of life.

10. When performing a postpartum assessment on a client, the LPN notes clots in the lochia. The LPN examines the clots and notes they are larger than 1 cm. Which of the following nursing actions is appropriate?

Document the findings

Notify the registered nurse (RN).

Reassess the client in 2 hours

Encourage increased oral intake of fluids

Normally there may be a few small clots in the first 1 to 2 days after birth from pooling of the blood in the vagina. Clots larger than 1 cm are considered abnormal. The cause of such clots, such as uterine atony or retained placental fragments, needs to be determined and treated to prevent further blood loss. Although the findings would be documented, the most appropriate action is to notify the RN. Reassessing the client in 2 hours would delay necessary treatment. Increasing oral intake of fluids would not be an appropriate action in this situation.

Explanation

Normally there may be a few small clots in the first 1 to 2 days after birth from pooling of the blood in the vagina. Clots larger than 1 cm are considered abnormal. The cause of such clots, such as uterine atony or retained placental fragments, needs to be determined and treated to prevent further blood loss. Although the findings would be documented, the most appropriate action is to notify the RN. Reassessing the client in 2 hours would delay necessary treatment. Increasing oral intake of fluids would not be an appropriate action in this situation.

11. A client in the postpartum unit complains of sudden sharp chest pain. The nurse notes that the client is tachycardic and the respiratory rate is elevated. The nurse suspects a pulmonary embolism. The initial nursing action would be which of the following?

Check the client’s blood pressure

Prepare for the insertion of an intravenous (IV) line.

Prepare to administer oxygen at 8 to 10 L by tight face mask

Prepare to administer morphine sulfate

If pulmonary embolism is suspected, oxygen should be administered at 8 to 10 L by tight face mask. Oxygen is used to decrease hypoxia. The woman also is kept on bedrest with the head of the bed slightly elevated to reduce dyspnea. Morphine sulfate may be prescribed for the client, but this action would not be the initial nursing action. An IV line also will be required, but this action would follow the administration of the oxygen.

Explanation

If pulmonary embolism is suspected, oxygen should be administered at 8 to 10 L by tight face mask. Oxygen is used to decrease hypoxia. The woman also is kept on bedrest with the head of the bed slightly elevated to reduce dyspnea. Morphine sulfate may be prescribed for the client, but this action would not be the initial nursing action. An IV line also will be required, but this action would follow the administration of the oxygen.

12. A nurse in the newborn nursery receives a telephone call to prepare for the admission of an infant born at 43 weeks gestation with Apgar scores of 1 and 4. When planning for the admission of this infant, the nurse's highest priority should be:

Turn on the apnea and cardiorespiratory monitor

Connect the resuscitation bag to the oxygen outlet

Set up the intravenous line with 5% dextrose in water

Set the radiant warmer control temperature at 36.5oC (97.6oF)

The highest priority during the admission to the nursery of a newborn with low Apgar scores is airway support, which would involve preparing respiratory resuscitation equipment. The remaining options are also important although they are of lower initial priority.

Explanation

The highest priority during the admission to the nursery of a newborn with low Apgar scores is airway support, which would involve preparing respiratory resuscitation equipment. The remaining options are also important although they are of lower initial priority.

13. A mother of a newborn calls the clinic and reports to the nurse that when she was cleansing the newborn's umbilical cord, the cord was moist and discharge was noted. The appropriate nursing instruction to the mother is which of the following?

To increase the number of times that the cord is cleansed per day

To monitor the cord for another 24 to 48 hours and to call the clinic if the discharge continues

To bring the infant to the clinic

That this is a normal occurrence

Symptoms of infection are moistness, oozing, discharge, and a reddened base around the cord. If symptoms of infection occur, the mother should be instructed to notify a health care provider. If these symptoms occur, antibiotics are necessary. Options 1, 2, and 4 are inappropriate nursing interventions.

Explanation

Symptoms of infection are moistness, oozing, discharge, and a reddened base around the cord. If symptoms of infection occur, the mother should be instructed to notify a health care provider. If these symptoms occur, antibiotics are necessary. Options 1, 2, and 4 are inappropriate nursing interventions.

14. Match the following anthropomorphic measurements of a term newborn in the left column with their appropriate value on the right.

1. Head circumference a. 30 - 33 cm 2. Chest circumference b. 33 - 37 cm 3. Weight c. 2500 - 4000 gm 4. Length d. 45-55 cm

1. _____ 2. _____ 3. _____ 4. _____

not-available-via-ai

Explanation

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15. A nurse is required to apply ice packs to a client who has had a vaginal delivery. Which of the following interventions should the nurse perform to ensure the client gets the optimum benefit from the procedure?

Apply ice packs directly to the perineal area

Apply ice packs for 40 minutes continuously

Ensure ice pack is changed frequently

Use ice packs for a week after delivery

The nurse should ensure that the ice pack is changed frequently to promote good hygiene and to allow for periodic assessments. Ice packs are wrapped in a disposable covering or clean wash cloth and then applied to the perineal area, not directly. The nurse should apply the ice pack for 20 minutes, not 40. Ice packs should be used for the first 24 hours, not for a week after delivery.

Explanation

The nurse should ensure that the ice pack is changed frequently to promote good hygiene and to allow for periodic assessments. Ice packs are wrapped in a disposable covering or clean wash cloth and then applied to the perineal area, not directly. The nurse should apply the ice pack for 20 minutes, not 40. Ice packs should be used for the first 24 hours, not for a week after delivery.

16. A nurse is providing instructions to the mother following delivery regarding care of the episiotomy site to prevent infection. Which statement by the mother indicates a need for further instructions?

“I will wipe my perineum from front to back after voiding and defecation.”

“I will use warm water or an irrigation device to rinse the perineum after elimination.”

“I will change the perineum pads three times a day.”

“I will take warm sitz baths three times a day.”

Warm sitz baths and cleansing with warm water are helpful for relieving pain, and these measures will promote cleanliness in the perineum area to prevent infection. The mother should also be instructed to wipe the perineum from front to back after voiding and defecation to decrease the risk for contamination with microorganisms from the anus to the vagina. Warm water should be used to rinse the perineum after elimination. The mother also should be instructed that the perineal pad should be changed after each elimination and may be changed in between.

Explanation

Warm sitz baths and cleansing with warm water are helpful for relieving pain, and these measures will promote cleanliness in the perineum area to prevent infection. The mother should also be instructed to wipe the perineum from front to back after voiding and defecation to decrease the risk for contamination with microorganisms from the anus to the vagina. Warm water should be used to rinse the perineum after elimination. The mother also should be instructed that the perineal pad should be changed after each elimination and may be changed in between.

17. After episiotomy and the delivery of a newborn, the nurse performs a perineal check on the mother. The nurse notes a trickle of bright red blood coming from the perineum. The nurse checks the fundus and notes that it is firm. The nurse determines that:

This is a normal expectation after episiotomy

The mother should be allowed bathroom privileges only

The bright red bleeding is abnormal and should be reported

The perineal assessment should be performed more frequently

Lochial flow should be distinguished from bleeding that originates from a laceration or an episiotomy, which is usually brighter red than lochia and presents as a continuous trickle of bleeding, even though the fundus of the uterus is firm. This bright red bleeding is abnormal and needs to be reported.

Explanation

Lochial flow should be distinguished from bleeding that originates from a laceration or an episiotomy, which is usually brighter red than lochia and presents as a continuous trickle of bleeding, even though the fundus of the uterus is firm. This bright red bleeding is abnormal and needs to be reported.

18. A nurse in the delivery room is assisting with the delivery of a newborn. The nurse prepares to prevent heat loss in the newborn due to conduction by:

Wrapping the newborn in a blanket

Closing the doors to the delivery room

Drying the newborn with a warm blanket

Warming the crib pad before placing the newborn in the crib

Hypothermia caused by conduction occurs when the newborn is on a cold surface such as a pad or mattress and heat from the newborn’s body is transferred to the colder object. Warming the crib pad will assist in preventing hypothermia by conduction. Evaporation of moisture from a wet body dissipates heat along with the moisture. Drying the wet newborn at birth will prevent hypothermia via evaporation. Convection occurs as air moves across the newborn’s skin from an open door and heat is transferred to the air. Radiation occurs when heat from the newborn radiates to a colder surface.

Explanation

Hypothermia caused by conduction occurs when the newborn is on a cold surface such as a pad or mattress and heat from the newborn’s body is transferred to the colder object. Warming the crib pad will assist in preventing hypothermia by conduction. Evaporation of moisture from a wet body dissipates heat along with the moisture. Drying the wet newborn at birth will prevent hypothermia via evaporation. Convection occurs as air moves across the newborn’s skin from an open door and heat is transferred to the air. Radiation occurs when heat from the newborn radiates to a colder surface.

19. The nurse is preparing to care for a newborn who is receiving phototherapy. Choose the measures that would be implemented. (Select all that apply)

Avoid stimulation

Cover the newborn's eyes with shields or patches

Expose all of the newborn's skin

Monitor the skin temperature closely

Reposition the newborn every 2 hours

Phototherapy is the use of intense fluorescent lights to reduce serum bilirubin levels in the newborn. Injury from treatment (eye damage, dehydration, sensory deprivation) can occur. Interventions include exposing as much of the newborn's skin as possible; however, the genital area is covered. The newborn's eyes are also covered with shields or patches to ensure the eyelids are closed. The shields are removed at least once/shift to inspect the eyes for infection or irritation and to allow for eye contact. The nurse measures the quantity of light every 8 hours, monitors the skin temperature closely, and increases fluids to compensate for water loss. The newborn will have loose green stools and green colored urine. The newborn's skin color is monitored every 4-8 hours with the fluorescent light turned off. The nurse monitors for bronze baby syndrome, which is a grayish-brown discoloration of the skin. The newborn is repositioned every 2 hours, and stimulation is provided. After treatment the infant is monitored for signs of hyperbilirubinemia, because rebound elevations are normal after therapy is discontinued.

Explanation

Phototherapy is the use of intense fluorescent lights to reduce serum bilirubin levels in the newborn. Injury from treatment (eye damage, dehydration, sensory deprivation) can occur. Interventions include exposing as much of the newborn's skin as possible; however, the genital area is covered. The newborn's eyes are also covered with shields or patches to ensure the eyelids are closed. The shields are removed at least once/shift to inspect the eyes for infection or irritation and to allow for eye contact. The nurse measures the quantity of light every 8 hours, monitors the skin temperature closely, and increases fluids to compensate for water loss. The newborn will have loose green stools and green colored urine. The newborn's skin color is monitored every 4-8 hours with the fluorescent light turned off. The nurse monitors for bronze baby syndrome, which is a grayish-brown discoloration of the skin. The newborn is repositioned every 2 hours, and stimulation is provided. After treatment the infant is monitored for signs of hyperbilirubinemia, because rebound elevations are normal after therapy is discontinued.

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20. A nurse is preparing a list of self-care instructions for a postpartum client who has been diagnosed with mastitis. Choose the instructions that would be included on the list (Select all that apply)

Wear a supportive bra

Rest during the acute phase

Maintain fluid intake of at least 3000 ml

Continue to breastfeed if the breasts are not too sore

Take the prescribed antibiotics until the soreness subsides

Mastitis is an infection of the lactating breast. Client instructions include resting during the acute phase, maintaining a fluid intake of at least 3000 ml per day, and taking analgesics to relieve discomfort. Antibiotics may be prescribed and are taken until the complete prescribed course is finished; they are not stopped when soreness subsides. Additional supportive measures include the use of moist heat or ice packs and the wearing of a supportive bra. Continued decompression of the breast by breastfeeding or breast pump is important to empty the breast and prevent the formation of an abscess.

Explanation

Mastitis is an infection of the lactating breast. Client instructions include resting during the acute phase, maintaining a fluid intake of at least 3000 ml per day, and taking analgesics to relieve discomfort. Antibiotics may be prescribed and are taken until the complete prescribed course is finished; they are not stopped when soreness subsides. Additional supportive measures include the use of moist heat or ice packs and the wearing of a supportive bra. Continued decompression of the breast by breastfeeding or breast pump is important to empty the breast and prevent the formation of an abscess.

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Nursing care Of The Client With Special Needs Quiz