Nursing Elites

1. The client is being taught about perineal care postpartum. Which instruction should the client receive?

• A. Use ice packs to reduce swelling for the first 24 hours.
• B. Apply heat packs immediately after birth to reduce pain.
• C. Avoid using a peri-bottle to cleanse the perineum.
• D. Use tampons to absorb lochia discharge.

Correct answer: A

Rationale: The correct instruction for the client postpartum is to use ice packs to reduce swelling for the first 24 hours. This helps alleviate discomfort and promote healing. Applying heat packs immediately after birth is not recommended as they can increase swelling. A peri-bottle is advised for cleansing the perineum, not to be avoided. Tampons should not be used to absorb lochia discharge as they can increase the risk of infection. Therefore, the use of ice packs is the most appropriate and beneficial instruction for perineal care postpartum.

2. During the 5-minute Apgar assessment of a newborn, you note a heart rate of 130 beats/min, cyanosis in the hands and feet, and rapid respirations. The baby cries when you flick the soles of its feet and resists leg straightening. These findings correspond to an Apgar score of:

• A. 9
• B. 7
• C. 8
• D. 10

Correct answer: A

Rationale: The Apgar score is a rapid assessment tool to evaluate the newborn's transition to life outside the womb. The Apgar score is based on five components: heart rate (>100 bpm), respiratory effort (rapid breathing), muscle tone (resisting leg straightening), reflex irritability (crying when feet are flicked), and color (cyanosis to extremities). The described findings match a score of 9, indicating good overall condition and adaptation to extrauterine life.

3. A 2-year-old client is admitted for an acute asthma episode. The hospital provides family-centered care. In explaining the program to the parents, the nurse would explain that the parents are:

• A. Required to implement all personal hygiene care for their child.
• B. Encouraged to be as involved with the child's care as they are comfortable being.
• C. Requested to administer all oral medications.
• D. Expected to be present at the child's bedside.

Correct answer: B

Rationale: Family-centered care involves encouraging parents to actively participate in their child's care based on their comfort level. This approach promotes collaboration between healthcare providers and families, enhancing the quality of care and ensuring the family's involvement in decision-making. Choice A is incorrect because parents are encouraged to participate, not required to implement all personal hygiene care. Choice C is incorrect as it implies a specific action rather than the broader concept of involvement. Choice D is incorrect as it focuses solely on physical presence rather than active participation in care.

4. A 6-year-old child is admitted to the hospital with pneumonia. An immediate priority in this child's nursing care would be:

• A. Elimination
• B. Exercise
• C. Nutrition
• D. Rest

Correct answer: D

Rationale: Rest is crucial for recovery in a child with pneumonia as it allows the body to focus its energy on fighting the infection and promoting healing. Adequate rest helps reduce the workload on the lungs, promotes oxygenation, and supports the immune system's response to combat the infection. It is essential to prioritize rest to facilitate a faster recovery and prevent complications in children with pneumonia.

5. Serwaa, a 26-year-old mother, has brought her daughter to the OPD with signs of lower respiratory tract infection. Which of the following diagnoses is NOT typically associated with lower respiratory tract infections for her daughter?

• A. Pneumonia
• B. Asthma
• C. Bronchiolitis
• D. Coryza

Correct answer: D

Rationale: Coryza, also known as the common cold, is a viral infection that primarily affects the upper respiratory tract and is not typically associated with lower respiratory tract infections. Pneumonia, asthma, and bronchiolitis are conditions that commonly affect the lower respiratory tract, causing symptoms like cough, difficulty breathing, and chest pain.

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