Quiz 3 : Nursing care Of The Client With Special Needs

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Quiz 3 : Nursing care Of The Client With Special Needs - Quiz

Select the best response to the question from the answers provided.


Questions and Answers
  • 1. 

    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:

    • A.

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

    • B.

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

    • C.

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

    • D.

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

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

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  • 2. 

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

    • A.

      Your newborn needs vitamin K to develop immunity

    • B.

      The vitamin K will protect the newborn from becoming jaundiced

    • C.

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

    • D.

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

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

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  • 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?

    • A.

      Monitor the neonate's vital signs routinely

    • B.

      Maintain standard precautions at all times while caring for the neonate

    • C.

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

    • D.

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

    Correct Answer
    B. Maintain standard precautions at all times while caring for the 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.

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  • 4. 

    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:

    • A.

      Turn on the apnea and cardiorespiratory monitor

    • B.

      Connect the resuscitation bag to the oxygen outlet

    • C.

      Set up the intravenous line with 5% dextrose in water

    • D.

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

    Correct Answer
    B. Connect the resuscitation bag to the oxygen outlet
    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.

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  • 5. 

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

    • A.

      Pink, without drainage

    • B.

      Reddened, with a small amount of bloody drainage

    • C.

      Reddened with a small amount of yellow exudate on the glans

    • D.

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

    Correct Answer
    B. Reddened, with a small amount of bloody drainage
    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.

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  • 6. 

    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:

    • A.

      Tachypnea and retractions

    • B.

      Acrocyanosis and grunting

    • C.

      Hypotension and bradycardia

    • D.

      The presence of a barrel chest with acrocyanosis

    Correct Answer
    A. Tachypnea and retractions
    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.

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  • 7. 

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

    • A.

      Avoid stimulation

    • B.

      Cover the newborn's eyes with shields or patches

    • C.

      Expose all of the newborn's skin

    • D.

      Monitor the skin temperature closely

    • E.

      Reposition the newborn every 2 hours

    Correct Answer(s)
    B. Cover the newborn's eyes with shields or patches
    D. Monitor the skin temperature closely
    E. Reposition the newborn every 2 hours
    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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  • 8. 

    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)

    • A.

      Wear a supportive bra

    • B.

      Rest during the acute phase

    • C.

      Maintain fluid intake of at least 3000 ml

    • D.

      Continue to breastfeed if the breasts are not too sore

    • E.

      Take the prescribed antibiotics until the soreness subsides

    Correct Answer(s)
    A. Wear a supportive bra
    B. Rest during the acute phase
    C. Maintain fluid intake of at least 3000 ml
    D. Continue to breastfeed if the breasts are not too sore
    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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  • 9. 

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

    • A.

      Apply cool packs to the abdomen

    • B.

      Continue to monitor the temperature

    • C.

      Remove the blanket from the client's bed

    • D.

      Notify the Registered Nurse, who will then contact the physician

    Correct Answer
    D. Notify the Registered Nurse, who will then contact the physician
    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.

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  • 10. 

    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:

    • A.

      This is a normal expectation after episiotomy

    • B.

      The mother should be allowed bathroom privileges only

    • C.

      The bright red bleeding is abnormal and should be reported

    • D.

      The perineal assessment should be performed more frequently

    Correct Answer
    C. The bright red bleeding is abnormal and should 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.

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  • 11. 

    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:

    • A.

      Checks the vital signs

    • B.

      Begins fundal message

    • C.

      Encourages ambulation

    • D.

      Encourages the client to drink fluids

    Correct Answer
    A. Checks the vital signs
    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.

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  • 12. 

                  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?

    • A.

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

    • B.

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

    • C.

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

    • D.

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

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

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  • 13. 

    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?

    • A.

      Check the client’s blood pressure

    • B.

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

    • C.

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

    • D.

      Prepare to administer morphine sulfate

    Correct Answer
    C. Prepare to administer oxygen at 8 to 10 L by tight face mask
    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.

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  • 14. 

    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?

    • A.

      Apply ice packs directly to the perineal area

    • B.

      Apply ice packs for 40 minutes continuously

    • C.

      Ensure ice pack is changed frequently

    • D.

      Use ice packs for a week after delivery

    Correct Answer
    C. Ensure ice pack is changed frequently
    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.

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  • 15. 

    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?  

    • A.

      Hold the newborn

    • B.

      Speak to his friends

    • C.

      Read up on parental care

    • D.

      Speak to the physician

    Correct Answer
    A. Hold the newborn
    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.

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  • 16. 

    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:

    • A.

      Wrapping the newborn in a blanket

    • B.

      Closing the doors to the delivery room

    • C.

      Drying the newborn with a warm blanket

    • D.

      Warming the crib pad before placing the newborn in the crib

    Correct Answer
    D. Warming the crib pad before placing the newborn in the crib
    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.

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  • 17. 

    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.  _____

    Correct Answer
    b, a, c, d
    B A C D
  • 18. 

    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)?

    • A.

      Monitor oxygen concentration level

    • B.

      Monitor bilirubin level

    • C.

      Check the hemoglobin level

    • D.

      Check the pupil response

    Correct Answer
    A. Monitor oxygen concentration level
    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.

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  • 19. 

    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?

    • A.

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

    • B.

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

    • C.

      To bring the infant to the clinic

    • D.

      That this is a normal occurrence

    Correct Answer
    C. To bring the infant to the clinic
    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.

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  • 20. 

    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?

    • A.

      Document the findings

    • B.

      Notify the registered nurse (RN).

    • C.

      Reassess the client in 2 hours

    • D.

      Encourage increased oral intake of fluids

    Correct Answer
    B. Notify the registered nurse (RN).
    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.

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