Nursing care Of The Client With Special Needs Quiz

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.

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.

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

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.

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.

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

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

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

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

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

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)

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

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 cm1. _____   2. _____   3. _____  4.  _____

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

              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.”

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

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

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

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