NCLEX Practice Exam for Health Promotion and Maintenance

EXPLANATION

✔Correct answer:

Use an oral syringe to place the medication inside the infant's cheek. The safest and most effective way to administer oral medication to an infant is to use an oral syringe and place the medication inside the infant's cheek (the buccal area). This approach helps prevent the infant from choking or aspirating, as delivering the medication slowly into the cheek allows for controlled swallowing. The buccal area is an ideal location because it triggers a natural swallowing reflex in infants, reducing the risk of gagging or spitting the medication out.

An oral syringe provides precision in dosing and control over the rate of administration, ensuring that baby Liam receives the full dose safely.

Think of giving medication to an infant as similar to watering a delicate plant; you want to direct the water gently to one side rather than pouring it directly on the center. This way, you avoid overwhelming the plant. Placing the syringe inside the cheek gently directs the medication, making it easier for the baby to swallow.

To ensure safe administration of medication to infants, Nurse Maria should consider the following steps.

• Position the infant in a semi-upright or upright position to reduce the risk of choking and to facilitate swallowing.
• Use a slow and gentle approach, administering the medication a little at a time to avoid overwhelming the infant.
• Ensure that the dosage is accurate by using a calibrated oral syringe, which is more precise than other tools like droppers or spoons.
• Observe the infant for any signs of discomfort or difficulty swallowing, and pause if necessary.
• Provide positive reinforcement, such as a comforting touch or soothing words, to help keep the infant calm during the process.

✘Incorrect answer options:

Place the medication directly onto the back of the infant's tongue. This approach increases the risk of gagging and aspiration, as infants have a sensitive gag reflex. Administering the medication into the cheek is safer, as it allows the infant to swallow the medication more naturally.

Mix the medication into a full bottle of formula. Mixing medication into a full bottle is not recommended because the infant may not finish the entire bottle, resulting in an incomplete dose. Additionally, some medications may not mix evenly or could interact with formula, affecting their effectiveness.

Administer the medication while the infant is lying flat on their back. Administering medication with the infant lying flat increases the risk of aspiration, as the medication could flow towards the back of the throat and enter the airway. It is safer to have the infant in a semi-upright position.

EXPLANATION

✔Correct answer:

Wide-set eyes, a smooth philtrum, and a flattened nose. Fetal Alcohol Syndrome (FAS) is a condition caused by maternal alcohol consumption during pregnancy, which can lead to various physical and developmental abnormalities. The most characteristic facial features associated with FAS include wide-set eyes, a smooth philtrum (the groove between the nose and upper lip), and a flattened or short nose. These features are a result of the teratogenic effects of alcohol on fetal development, particularly affecting the midface. In addition to facial anomalies, children with FAS may experience growth deficiencies and central nervous system abnormalities, such as developmental delays and behavioral issues.

These physical signs are often used as diagnostic criteria for FAS, especially when combined with a history of maternal alcohol use. Recognizing these facial features can help healthcare providers identify infants at risk for developmental and behavioral challenges related to prenatal alcohol exposure.

Think of FAS as a puzzle where certain characteristic facial features fit together as pieces, indicating a specific cause. When you see these “puzzle pieces” (like wide-set eyes, a smooth philtrum, and a flattened nose), it helps form the picture of Fetal Alcohol Syndrome.

Nurse Leah should assess for additional developmental and physical issues that may be associated with FAS and provide appropriate support and education.

• Monitor the newborn for growth deficiencies, as FAS can impact both weight and height.
• Assess for signs of central nervous system abnormalities, such as irritability, poor feeding, and potential developmental delays.
• Educate the parents on the importance of early intervention services, which may include physical, occupational, and speech therapies, to support the child's development.
• Provide guidance and resources for the parents, emphasizing the importance of routine follow-ups to monitor the infant's growth and developmental progress.
• Document the findings and consult with a pediatric specialist if needed for further evaluation and management of FAS.

✘Incorrect answer options:

Strong tongue thrust, short palpebral fissures, and a simian crease. While short palpebral fissures (the horizontal opening of the eyes) are associated with FAS, a simian crease (a single line across the palm) and strong tongue thrust are more characteristic of Down syndrome rather than FAS.

Absence of the Babinski reflex, hyperreflexia, and hearing loss. These signs are not typical indicators of FAS. The Babinski reflex is normally present in infants and should not be absent at birth. While hearing loss may occur in children with FAS, it is not a primary diagnostic criterion. Hyperreflexia is also not commonly associated with FAS.

Shortened limbs, increased jitteriness, and persistent sucking. Shortened limbs and persistent sucking are not specific to FAS. Increased jitteriness may be present but is not one of the primary signs. These symptoms are more likely to be seen in infants with neonatal abstinence syndrome (NAS) due to opioid or other drug exposure rather than FAS.

EXPLANATION

✔Correct answer:

Reduced size of the nose and ears. A reduced size of the nose and ears is not typically associated with aging. In fact, as people age, the ears and nose often appear to get larger. This phenomenon is due to the fact that cartilage continues to grow and change over time, and gravity causes the skin and tissues to sag. Additionally, the soft tissue of the nose may elongate with age, giving the appearance of a larger nose. These changes in cartilage and skin elasticity contribute to the perception of larger ears and noses in elderly individuals.

In contrast, the other options listed are indeed associated with the normal aging process. Increased facial hair, deep wrinkles, and wrinkles on the neck are all commonly seen physical changes in elderly individuals.

Think of cartilage in the nose and ears like the branches of a tree that keep growing over time, even when the tree itself has stopped growing in height. This ongoing change is why the nose and ears seem to get larger with age, rather than reducing in size.

When assessing elderly clients, Nurse Dana should be aware of normal age-related changes versus changes that may indicate potential health issues.

• Observe physical changes in the face, head, and neck to differentiate normal aging from signs that may need further assessment (e.g., asymmetry or unusual growths).
• Educate the client and family about normal age-related changes, providing reassurance as needed.
• Assess for changes in skin integrity, hydration, and elasticity, as elderly clients are at higher risk for skin breakdown.
• Document findings accurately, especially if any changes are unusual or require further evaluation.
• Provide resources on skincare and grooming for elderly clients, which can support comfort and self-esteem despite age-related physical changes.

✘Incorrect answer options:

Deep wrinkles on the face. Wrinkles, especially deep facial wrinkles, are a normal part of the aging process due to the gradual loss of skin elasticity, collagen, and subcutaneous fat.

Increased facial hair growth. Increased facial hair, particularly in women, is common with aging. This occurs due to hormonal changes, such as reduced estrogen levels, which can lead to an increase in facial hair growth.

Wrinkles on the neck. Wrinkles and sagging skin on the neck are also common with aging, as the skin loses elasticity and collagen, and gravity causes it to sag over time.

EXPLANATION

✔Correct answer:

Give clear and accurate information about the condition and available treatments. When a patient receives a serious diagnosis like a stage IV brain tumor, one of the most effective forms of support a nurse can provide is clear and honest communication about the diagnosis and treatment options. At this stage, Mr. Greene is likely experiencing a range of emotions, including fear, anxiety, and uncertainty. By giving him clear and accurate information, Nurse Rachel can help him understand his condition better, which can reduce anxiety, facilitate informed decision-making, and foster a sense of control over the situation. Accurate information also builds trust between the patient and healthcare team, showing that Nurse Rachel is a reliable source of support during this difficult time.

Providing factual information allows Mr. Greene to process the reality of his diagnosis and prepare mentally and emotionally for the journey ahead, including discussing possible treatment options, palliative care, or quality of life considerations.

Think of this approach like providing a map to someone traveling in unfamiliar territory. When people know where they are and understand the path ahead, they can make informed decisions and feel less lost, even if the journey is difficult.

Nurse Rachel should consider the following interventions to provide compassionate, patient-centered care.

• Assess Mr. Greene’s understanding of his diagnosis and fill in any knowledge gaps, using language that is clear and appropriate to his comprehension level.
• Encourage Mr. Greene to ask questions, which helps him clarify uncertainties and enables more personal involvement in decision-making.
• Provide information about treatment options, possible side effects, and support resources, so he can start to consider his preferences and priorities.
• Offer emotional support and acknowledge his feelings, validating any fear, anger, or sadness he might express.
• Encourage the presence of family members if Mr. Greene wishes, as family support can be beneficial in processing the information and making decisions.

✘Incorrect answer options:

Provide pamphlets about brain cancer support groups. While support groups can be beneficial, this is not the most immediate or personal form of support for a patient who has just received a severe diagnosis. Pamphlets alone might feel impersonal, and Mr. Greene may first need direct information about his condition and treatment options before considering support groups.

Ask if the client or his family needs anything at the moment. Although this is a compassionate approach, it is somewhat vague and does not address Mr. Greene's immediate need for information about his condition. He may not know what he needs or what to ask for without a better understanding of his diagnosis and prognosis.

Reassure the client that medical technology is advancing daily. This statement might provide temporary comfort, but it can come across as dismissive of the severity of Mr. Greene’s diagnosis. It might also create unrealistic expectations about his prognosis or treatment outcomes, which could lead to frustration or loss of trust if advancements in technology are not directly relevant to his care.

EXPLANATION

✔Correct answer:

Holding a rattle. At around 4 months of age, infants typically begin to develop better hand-eye coordination and grasping abilities, which enables them to hold objects such as a rattle for brief periods. This is an appropriate and expected motor skill for this age, as infants start to develop voluntary grasping around 3 to 4 months. At this stage, infants have the ability to reach out for objects and can briefly hold onto them, although their grip may still be somewhat unsteady.

Holding a rattle helps foster fine motor development and sensory engagement, allowing the infant to explore textures, sounds, and movements as they learn to coordinate their hand movements with what they see.

Imagine the infant’s hand strength and coordination like learning to hold onto a handle while swinging on a playground. At first, they might hold the handle briefly, learning the feel and control needed, just as infants learn to hold a small object like a rattle.

Nurse Olivia should assess and encourage age-appropriate developmental milestones and offer guidance to parents on how to support motor skills development.

• Provide the infant with safe, lightweight objects (such as rattles) that are easy to grasp, helping them practice their emerging grasping skills.
• Educate parents on developmental milestones for the next few months, such as reaching, transferring objects between hands, and improved hand control.
• Encourage parents to engage with the infant using toys that stimulate visual and tactile senses, such as rattles, soft toys, and other safe items.
• Observe for any delays in motor skills and provide guidance on activities that support physical development, or refer to early intervention services if needed.
• Document the infant’s ability to grasp and hold onto objects, as this is an important developmental milestone for fine motor skills.

✘Incorrect answer options:

Banging two blocks together. This skill generally develops around 9-12 months of age, when infants gain more advanced coordination and control over their hands. At 4 months, infants are not yet able to intentionally bring objects together in this manner.

Drinking from a cup. Drinking from a cup usually begins around 6-9 months, with assistance, and becomes more developed by 12 months. At 4 months, infants are not developmentally ready for this skill.

Waving "bye-bye." Waving typically emerges around 9-12 months as infants begin to understand gestures and social interactions. This behavior requires both motor skills and social-cognitive development, which are not yet present at 4 months.

EXPLANATION

✔Correct answer:

Feed the infant glucose water (10%). The most appropriate intervention for a newborn exhibiting signs of jitteriness and lethargy, particularly when born to a mother with diabetes, is to address the possibility of hypoglycemia. Infants of diabetic mothers are at higher risk for hypoglycemia due to the excess insulin they may produce in response to the high glucose levels they were exposed to in utero. When they are born, their endogenous insulin remains high, but the maternal glucose supply is cut off, leading to a potential drop in blood glucose levels.

Signs of hypoglycemia in newborns include jitteriness, lethargy, poor feeding, and even seizures if left untreated. Administering glucose water (10%) helps quickly raise the infant's blood glucose level, alleviating symptoms and preventing complications.

Imagine a car that’s used to getting fuel every hour but suddenly stops receiving it. Just like the car might sputter or stop, the baby’s body can “sputter” when blood sugar levels drop. Giving glucose is like adding fuel, helping the baby regain energy and stabilize.

When managing a newborn with potential hypoglycemia, the following interventions are essential.

• Immediately test the newborn’s blood glucose levels to confirm hypoglycemia.
• If the blood glucose is below safe limits, provide glucose water (10%) or begin feeding with formula/breast milk to help stabilize levels.
• Continue to monitor blood glucose levels closely, as hypoglycemia may recur.
• Observe for other symptoms, such as poor feeding, temperature instability, or respiratory distress, which may require additional interventions.
• Educate the mother about the signs of hypoglycemia and the importance of regular feedings to maintain stable blood sugar levels in her newborn.

✘Incorrect answer options:

Administer insulin. Insulin administration would further decrease the newborn’s blood glucose, worsening hypoglycemia. Insulin is not indicated in this case, as the issue is low blood sugar, not high.

Provide oxygen therapy. While oxygen may be beneficial if the newborn has respiratory distress, it does not address the underlying issue of hypoglycemia. Oxygen therapy is not a treatment for low blood glucose levels.

Place the newborn in a warmer. While maintaining a stable body temperature is essential, a warmer does not directly address hypoglycemia. Warmers are useful for preventing hypothermia, but the priority intervention here is to raise the infant’s blood glucose with glucose water.

EXPLANATION

✔Correct answer:

A tongue depressor and flashlight. To evaluate cranial nerves IX (Glossopharyngeal) and X (Vagus), Nurse Parker should use a tongue depressor and flashlight. These nerves are primarily involved in the functions of swallowing, gag reflex, and the control of certain muscles in the throat and soft palate. By using a tongue depressor, Nurse Parker can gently press on the tongue to observe the soft palate and uvula, assessing their symmetry and movement, which helps determine the function of cranial nerves IX and X. The flashlight allows for a clear view of the oropharynx during this assessment.

• Cranial Nerve IX (Glossopharyngeal): This nerve is responsible for taste sensation on the posterior third of the tongue and also plays a role in the gag reflex and swallowing.
• Cranial Nerve X (Vagus): This nerve affects the muscles of the soft palate, pharynx, and larynx, contributing to the gag reflex and swallowing as well. It also influences functions such as heart rate and gastrointestinal motility, but these are not typically assessed with this equipment.

Think of the tongue depressor and flashlight as tools that allow you to look into the "backstage" of the mouth and throat. Just like how a stage manager checks backstage to make sure all equipment and actors are in the right place, the nurse uses these tools to ensure the muscles and reflexes in the throat are functioning properly.

When assessing cranial nerves IX and X, it’s essential to prepare the client and ensure a proper technique to observe responses accurately.

• Explain the procedure to the client, as the sensation of the tongue depressor might trigger a gag reflex, which could be uncomfortable.
• Use the flashlight to get a clear view of the throat and observe the movement of the uvula when the client says "ah." Any deviation from the midline may indicate nerve dysfunction.
• Check for the gag reflex by gently stimulating the back of the throat with the tongue depressor, being careful to avoid triggering excessive discomfort.
• Assess swallowing function by asking the client to swallow, observing for any signs of difficulty or asymmetry.

✘Incorrect answer options:

A cotton ball. A cotton ball is typically used to assess light touch sensation, often for cranial nerve V (Trigeminal), not for cranial nerves IX and X, which are responsible for gag reflex and swallowing.

A pen light. While a pen light can help in general inspection of the mouth, it is insufficient on its own for assessing the gag reflex and pharyngeal movement. A tongue depressor is needed to provide better visibility and access to the back of the throat.

An ophthalmoscope. An ophthalmoscope is used to examine the retina and structures inside the eye, which is helpful for assessing cranial nerve II (Optic). It is not appropriate for evaluating cranial nerves IX and X, which involve throat and swallowing functions.

EXPLANATION

✔Correct answer:

Formula or breast milk. For infants up to around 12 months of age, breast milk or formula should be the primary and exclusive source of nutrition and fluids. Breast milk and formula provide all the necessary nutrients and hydration needed by infants in this age group. They contain the right balance of proteins, fats, vitamins, and minerals to support growth and development, as well as the appropriate fluid content to maintain hydration.

Introducing other fluids, like water or juice, before 12 months is generally discouraged, as it can displace essential nutrients and potentially cause digestive issues. Additionally, other fluids do not offer the caloric density or immune benefits that breast milk or formula provide. Infants’ digestive systems are not yet mature enough to handle many other fluids, and introducing these too early could increase the risk of dehydration, malnutrition, or imbalanced electrolytes.

Think of an infant’s nutrition needs as a plant that requires a specific type of soil to grow well. For the first year, breast milk or formula is like that perfect soil, providing everything the baby needs to thrive. Introducing other “soils” (like juice or water) can disrupt their growth by taking away essential nutrients.

Nurse Emma should provide clear guidance to the parents on safe feeding practices for infants under 12 months.

• Emphasize that breast milk or formula should be the exclusive source of nutrition for the first six months and the primary source up to 12 months.
• Explain that additional water is generally unnecessary for infants receiving breast milk or formula, as they are already adequately hydrated.
• Discourage the introduction of juices, which add unnecessary sugars and may lead to gastrointestinal issues in young infants.
• Provide guidance on feeding frequency and quantity for breast milk or formula to ensure the infant is getting adequate nutrition.
• Address any misconceptions the parents may have about introducing other liquids, and provide resources for further reading if needed.

✘Incorrect answer options:

Diluted nonfat dry milk. Nonfat dry milk is not appropriate for infants, as it lacks the necessary fats essential for brain development and is not formulated to meet an infant's nutritional needs. Regular milk, especially nonfat, should not be introduced until at least 12 months of age, and only whole milk should be given to support brain growth.

Warmed fruit juice. Fruit juice is not recommended for infants under 12 months, as it is high in sugars and low in essential nutrients. Introducing juice too early can lead to digestive issues, increased risk of cavities, and poor weight gain due to displacement of breast milk or formula.

Fluoridated tap water. Tap water should generally not be given to infants under 12 months as their primary fluid source. Breast milk or formula provides adequate hydration, and additional water is typically unnecessary. Excessive water can also put infants at risk of water intoxication due to their immature kidneys, which are unable to balance electrolytes effectively.

EXPLANATION

✔Correct answer:

"Show me where it hurts." When communicating with young children, particularly preschool-aged children (3-5 years old), it is essential to use simple, direct language that they can easily understand. Asking a 4-year-old to "show me where it hurts" is effective because it uses clear language and allows the child to participate actively in the assessment. Preschoolers are often better able to point or show something rather than describe it in detail, making this approach age-appropriate and more likely to yield useful information.

This approach is also non-threatening, inviting the child to participate without introducing unnecessary anxiety. Since preschoolers are concrete thinkers, they respond well to questions that are specific and actionable.

Communicating with a young child is like giving instructions for a simple game. You want to be clear and specific, so the child understands exactly what to do. Asking them to "show" rather than "explain" uses concrete terms that are easier for them to grasp.

When interacting with young children, Nurse Rachel should adapt her communication techniques to suit their developmental level.

• Use simple, short sentences and give specific instructions to avoid overwhelming or confusing the child.
• Use non-threatening language to reduce anxiety. Avoid medical jargon that may sound scary, and instead use words familiar to the child.
• Use visual aids, toys, or props if necessary to help the child feel more comfortable and engaged.
• Validate the child’s feelings by acknowledging any pain or discomfort they may express, which helps build trust.
• Involve the parent or caregiver in the assessment to provide additional comfort and support for the child.

✘Incorrect answer options:

"Other kids enjoy having their blood pressure taken." This statement might be confusing or even unhelpful to a 4-year-old. Children at this age do not necessarily respond to comparisons with others and may feel pressured rather than reassured by this approach. It may also come across as dismissive if the child feels scared.

"This will feel like a small stick in your arm." Describing a procedure as feeling like a "stick" could be misinterpreted by a young child and might create fear or anxiety about the pain. Preschoolers often take language literally, so it's best to avoid phrases that might sound painful or unclear to them.

"Anything you say to me will be kept private." Privacy is not a major concern for preschool-aged children, as they generally do not fully understand the concept of confidentiality. This type of statement is more appropriate for older children and adolescents who may have concerns about privacy.

EXPLANATION

✔Correct answer:

An undescended testicle. The primary risk factor for testicular cancer is a history of cryptorchidism, or undescended testicle(s). Males with an undescended testicle are at a significantly higher risk of developing testicular cancer later in life compared to those whose testes descend normally. This risk remains elevated even if the testicle was surgically corrected and brought into the scrotum (orchiopexy). The reason for this increased risk is believed to be related to abnormal testicular development associated with cryptorchidism, which may predispose the cells within the testicle to malignancy.

Testicular cancer most commonly affects young men between the ages of 15 and 35, so it is crucial for healthcare providers to identify risk factors like an undescended testicle during health assessments and encourage regular testicular self-exams.

Think of an undescended testicle like a plant that doesn’t get enough sunlight. Just as the plant might grow differently or even develop issues due to its unusual environment, an undescended testicle has a higher likelihood of developing problems due to its atypical development.

Nurse Alex should consider the following interventions to educate and support Ryan regarding his risk factors.

• Encourage Ryan to perform regular testicular self-exams, teaching him the proper technique to check for lumps or changes.
• Provide information on the signs and symptoms of testicular cancer, such as a painless lump, swelling, or heaviness in the scrotum.
• Discuss the importance of routine follow-up care with a healthcare provider, especially given his history of cryptorchidism.
• Address any questions or concerns Ryan may have about his risk for testicular cancer, and provide resources if needed.
• Document the presence of this risk factor in Ryan's health history for future reference and management.

✘Incorrect answer options:

A history of genital herpes. Genital herpes is a sexually transmitted infection caused by the herpes simplex virus (HSV), but it is not linked to an increased risk of testicular cancer. Genital herpes affects the skin and mucous membranes but does not influence the development of testicular malignancy.

A previous hydrocele. A hydrocele, which is an accumulation of fluid around the testicle, is generally benign and not directly associated with an increased risk of testicular cancer. While a hydrocele may occasionally co-occur with testicular tumors, it is not a risk factor for testicular cancer itself.

A history of measles. Measles, a viral infection, does not increase the risk of testicular cancer. There is no established connection between measles and testicular malignancies.

EXPLANATION

✔Correct answer:

"Have you noticed any changes in the strength or flow of your urine?" When assessing for potential prostate issues, it is crucial to ask about changes in urinary strength or flow. The prostate gland surrounds the urethra, and as it enlarges—often due to benign prostatic hyperplasia (BPH) or other conditions—it can constrict the urethra, leading to symptoms such as a weakened urinary stream, difficulty starting and stopping urination, or incomplete emptying of the bladder. These symptoms are common indicators of prostate enlargement or dysfunction.

This question helps Nurse Sam identify potential signs of prostate problems, which can impact urinary function due to the anatomical relationship between the prostate and urethra. Assessing for changes in urinary strength or flow is a priority as it directly relates to the condition of the prostate.

Think of the prostate as a ring around a garden hose. If the ring tightens or becomes larger, it can restrict the water flow through the hose. Similarly, an enlarged prostate can restrict urine flow through the urethra, causing a decrease in strength or flow.

When conducting a prostate health assessment, Nurse Sam should focus on urinary symptoms and other signs that may indicate prostate issues.

• Ask about the frequency of urination, especially nocturia (waking up at night to urinate), which is a common symptom of prostate enlargement.
• Inquire about any difficulties in starting or stopping urination, as well as any sensations of incomplete bladder emptying.
• Assess for any history of urinary tract infections, which can sometimes be associated with prostate problems.
• Educate the patient on potential symptoms of prostate problems, including changes in urinary patterns, and encourage regular prostate screenings.
• Document any reports of pain or discomfort during urination, which may warrant further investigation.

✘Incorrect answer options:

"Have you experienced any changes in how well you tolerate certain foods?" Dietary tolerance is not directly related to prostate issues. While gastrointestinal symptoms are important, they do not provide specific information about prostate health and are therefore not a priority in this context.

"Do you find yourself urinating frequently, especially in the morning?" Frequent urination, particularly at night (nocturia), is more characteristic of prostate issues. Morning frequency alone is less specific to prostate health, as it could be influenced by other factors such as fluid intake.

"Do you feel any burning sensation when urinating, or notice any unusual smell in your urine?" Burning or unusual odor may suggest a urinary tract infection or other urinary tract issues, but these symptoms are not specific to prostate problems. Prostate issues are more likely to present with changes in urinary flow and strength rather than burning or odor changes.

EXPLANATION

✔Correct answer:

Blepharoplasty. Blepharoplasty is the surgical procedure designed specifically to improve the appearance of the eyes by removing excess skin, fat, and sometimes muscle from the upper and/or lower eyelids. This procedure is commonly performed to address drooping eyelids or puffy under-eye bags, both of which can give a tired or aged appearance. By discussing blepharoplasty, Nurse Sarah is focusing on a procedure that aligns with the client’s goal to improve the look of their eyes.

Blepharoplasty can be both a cosmetic and functional procedure, as it can also improve vision in cases where excess eyelid skin impairs the visual field.

Think of blepharoplasty as trimming the overgrown "curtains" (excess eyelid skin) around a "window" (the eye) to enhance the appearance and clarity of the view.

Nurse Sarah should provide education on both the procedure itself and the necessary postoperative care for blepharoplasty.

• Explain the procedure in detail, emphasizing that it involves removing excess skin and possibly fat around the eyelids.
• Discuss possible risks and complications, including swelling, bruising, dry eyes, or infection, and explain how to recognize these signs.
• Educate the client on postoperative care, including keeping the head elevated, using cold compresses, and avoiding strenuous activities to aid in recovery.
• Encourage the client to avoid rubbing or touching the eye area to prevent infection and ensure proper healing.
• Set realistic expectations regarding the results of the surgery and the time needed for full recovery.

✘Incorrect answer options:

Rhinoplasty — Rhinoplasty is a surgical procedure that reshapes or reconstructs the nose. It does not address excess skin around the eyes or on the face and neck, making it irrelevant for the client’s goals.

Liposuction — Liposuction is a body-contouring procedure used to remove fat from areas like the abdomen, thighs, and arms. It does not remove skin or improve the appearance of the eyes, face, or neck, so it is not appropriate for this client’s concerns.

Mammoplasty — Mammoplasty is a term for breast surgery, including augmentation or reduction. It is unrelated to the face, neck, or eyes and would not be relevant for this client’s goals.

EXPLANATION

✔Correct answer:

Offer skin-to-skin contact with the parent to reduce stress and promote comfort. For a 2-month-old infant recovering from surgery, skin-to-skin contact, also known as "kangaroo care," is a highly beneficial intervention. Skin-to-skin contact helps regulate the infant’s heart rate, breathing, and temperature, which are critical factors for a stable recovery. It also has a calming effect on the infant, reducing pain and stress levels, as the release of oxytocin during this contact promotes bonding and comfort. Reducing stress and pain is particularly important for an infant recovering from surgery, as it can decrease cortisol levels, improve oxygenation, and facilitate faster healing.

Skin-to-skin contact is especially beneficial at this age because infants lack the coping mechanisms to manage stress on their own. Physical closeness with a caregiver provides the sense of safety and security they need, which is essential for both emotional and physiological recovery.

Think of skin-to-skin contact like a warm blanket on a cold day. Just as a warm blanket provides comfort and helps you feel calm and secure, skin-to-skin contact offers warmth, stability, and comfort for the infant, helping them relax and recover more effectively.

To enhance recovery for baby Noah, Nurse Clara should consider additional steps along with skin-to-skin contact.

• Encourage parents to engage in frequent skin-to-skin contact sessions, ensuring the infant’s head is positioned properly for safe breathing.
• Monitor the infant’s vital signs during skin-to-skin contact to ensure stability and comfort.
• Educate parents on the benefits of kangaroo care, emphasizing its role in pain relief and emotional bonding.
• Incorporate pain management strategies as needed, such as swaddling, using a pacifier, or administering prescribed medications if indicated.
• Maintain a quiet, comfortable environment to reduce external stressors that could disrupt the infant’s healing process.

✘Incorrect answer options:

Encourage tummy time to strengthen the infant's muscles. While tummy time is beneficial for muscle development and motor skills, it is not a priority intervention for an infant recovering from surgery. Additionally, tummy time may be uncomfortable for the infant immediately after surgery, depending on the location of the incision.

Provide small toys to stimulate cognitive development. While cognitive stimulation is important, it is not the primary focus during the early recovery phase after surgery. Infants at this age benefit more from comfort and stress reduction rather than cognitive play.

Maintain a consistent feeding schedule to promote healing. Although regular nutrition is essential for recovery, a consistent feeding schedule alone is not sufficient to address the infant's stress and pain. Skin-to-skin contact offers direct physiological and psychological benefits, making it the priority intervention.

EXPLANATION

✔Correct answer:

"Good morning. You’re in the hospital, and I am your nurse, Jenna." When caring for clients who are confused or experiencing memory issues, it’s important to provide clear, direct information that gently reorients them to their surroundings. This statement is effective because it includes essential details — the time of day ("Good morning"), the location ("You’re in the hospital"), and the caregiver’s role and name ("I am your nurse, Jenna"). This approach is supportive and non-confrontational, helping the client establish a sense of time, place, and person, which is crucial for reality orientation.

Reality orientation involves providing frequent reminders of the time, place, and people around the client to reduce confusion. The correct statement delivers these elements in a simple, reassuring manner that can help decrease the client’s disorientation without making them feel pressured to remember on their own.

Imagine waking up in a new place after a deep sleep; hearing clear information about where you are and who is with you helps you quickly regain your bearings. Similarly, this kind of statement helps orient the client without making them feel stressed or tested.

Nurse Jenna should incorporate reality orientation techniques into her care to support the client’s comfort and cognitive clarity.

• Use frequent and consistent cues about the time, place, and people around the client, including reminders at the beginning of each interaction.
• Maintain a calm and reassuring tone, as a comforting approach can reduce anxiety associated with disorientation.
• Encourage the client to participate in their care, which can help reinforce their sense of control and orientation.
• Provide visual aids in the room, such as a clock, calendar, or sign with the hospital’s name, to further support reality orientation.
• Document the client’s response to orientation cues and communicate any persistent disorientation to the healthcare team for further assessment or intervention.

✘Incorrect answer options:

"Good morning. Do you remember where you are?" This question places pressure on the client to remember on their own, which may cause frustration or increase anxiety if they are unable to recall. It’s better to provide clear information rather than asking them to retrieve it.

"Hello. My name is Jenna, and I am your nurse for today." While this statement introduces Nurse Jenna and her role, it lacks information about the client’s location, which is crucial for orienting a confused client who may not remember that they are in the hospital.

"How are you today? Remember, you’re in the hospital." Although this statement includes a reminder about the client’s location, the wording may feel accusatory or challenging ("Remember, you’re in the hospital"). This can create stress rather than reassurance, which is counterproductive in reality orientation.

EXPLANATION

✔Correct answer:

December 24. To calculate the estimated date of delivery (EDD), Nurse Jenna can use Naegele's Rule, which is a standard method for calculating the due date based on the first day of the client’s last menstrual period (LMP). Naegele's Rule is calculated as follows:

1. Take the first day of the last menstrual period (LMP).
2. Add 1 year.
3. Subtract 3 months.
4. Add 7 days.

In this case:

• LMP: March 17
• Add 1 year: March 17 of the following year (2024 if the current year is 2023)
• Subtract 3 months: December 17
• Add 7 days: December 24

Therefore, the estimated date of delivery (EDD) is December 24.

✘Incorrect answer options:

November 8 — This date does not align with Naegele's Rule calculations based on a March 17 LMP.

May 15 — This date is incorrect, as it falls earlier than the typical 40-week gestational period for a December due date.

February 21 — This is also incorrect; it would be too far ahead of the calculated due date based on Naegele’s Rule.

EXPLANATION

✔Correct answer:

Threatening to leave the child if they don’t sit down and be quiet. Threatening to leave a young child as a means of discipline is considered a negative and potentially harmful approach to family interaction. This type of statement may create feelings of insecurity, fear, and abandonment in the child, especially in a medical setting where they are likely already feeling anxious. Such language can damage trust between the parent and child, leading to increased anxiety and negative behavioral responses. Children, especially at the preschool age, need reassurance and support rather than threats or punishment, particularly in unfamiliar or stressful situations like a medical visit.

This behavior suggests a lack of appropriate coping mechanisms and an ineffective approach to managing the child’s behavior, indicating a potential issue with family dynamics or parenting style that may need further exploration and guidance.

Imagine telling someone who is nervous about flying, “If you don’t calm down, I’ll leave you here at the airport.” Instead of helping, this would likely increase their fear. Similarly, a child hearing they might be “left” if they don’t behave can feel even more scared and insecure.

Nurse Lily should consider additional supportive actions and resources for the family.

• Observe the interaction further to assess whether this behavior is part of a broader pattern that may suggest parenting challenges or stressors.
• Provide positive reinforcement to the parent by modeling supportive language and suggesting ways to reassure the child, such as validating the child’s feelings and offering comfort.
• Educate the parent on age-appropriate ways to communicate with and soothe a preschool-aged child, especially in medical or stressful settings.
• Refer the family to parenting resources or support groups if ongoing issues with family interaction are observed.
• Ensure a supportive environment for the child by offering comfort measures, such as allowing the parent to hold the child or use distraction techniques to ease the child’s anxiety.

✘Incorrect answer options:

Explaining that the injection will feel like a bee sting. This statement is a straightforward and honest way of preparing the child for a medical procedure. Explaining what to expect in simple terms is a positive approach that helps the child feel prepared and builds trust between the parent and child.

Offering to hold the child in her lap while the injection is given. This behavior shows empathy and support, which helps the child feel safe and secure. Physical closeness with a trusted caregiver can reduce anxiety and help the child cope with the stress of the procedure.

Comforting the child by saying it’s okay to cry. Acknowledging the child’s emotions and letting them know it’s okay to cry is a supportive response. It validates the child’s feelings and encourages healthy emotional expression, which is important for emotional development and family bonding.

EXPLANATION

✔Correct answer:

"Can you tell me why you don’t want to take your medication?" The most appropriate response in this situation is to ask the client why they don’t want to take their medication. This approach is therapeutic, patient-centered, and allows Nurse Jordan to explore the client’s concerns, which may include side effects, lack of understanding about the medication, or personal beliefs that impact adherence. By asking an open-ended question, Nurse Jordan can gather more information, which can help in addressing the client's concerns and in facilitating informed decision-making. This approach also builds rapport and trust, showing the client that their feelings and reasons are valued and understood.

Understanding the reason for refusal is an essential first step before any other actions, as it provides Nurse Jordan with the opportunity to address the client’s concerns, provide education if needed, or explore alternatives if appropriate.

Imagine a friend saying they don’t want to attend an event. Instead of assuming or insisting, you’d ask, “Why don’t you want to go?” This helps you understand their reason and find a solution together. Similarly, asking the client “why” helps Nurse Jordan understand and address the client’s needs regarding the medication.

Nurse Jordan should use a patient-centered approach to encourage understanding and support informed decision-making.

• Listen actively to the client’s concerns and validate their feelings, which can build trust and encourage honest communication.
• Provide clear and accurate information about the medication’s purpose, potential side effects, and benefits, to address any misconceptions.
• If the client is experiencing side effects or other issues, discuss possible adjustments or alternative therapies with the healthcare provider.
• Document the client’s refusal and the reason given, as well as any educational efforts or actions taken to support informed decision-making.
• Notify the healthcare provider if refusal persists, so they can participate in the discussion and consider adjusting the treatment plan if necessary.

✘Incorrect answer options:

"That's fine, it's okay to skip your medication occasionally." This response is inappropriate as it minimizes the importance of the medication regimen and could imply that it’s acceptable to skip doses without consequence. It does not address the underlying reasons for the client's refusal or provide an opportunity to educate them about their treatment.

"I'll need to inform your doctor about this." While notifying the physician is necessary if the client refuses medication after discussion, this response may come across as dismissive and authoritarian. It could make the client feel that their concerns are not being heard and discourage open communication.

"Do you understand what might happen if you refuse your treatment?" This response could be perceived as confrontational or even threatening. It focuses on the consequences of non-adherence rather than exploring the client's reasons for refusal and may create a barrier to further communication. The nurse should prioritize understanding the client's perspective first.

EXPLANATION

✔Correct answer:

Participating in cooperative play with other children their age. At around 4 years of age, children are typically in the preschool stage of development, as described by developmental theorists such as Jean Piaget and Erik Erikson. During this stage, children begin to engage in cooperative play, where they interact with other children, share toys, and work together towards a common goal, such as building a structure or engaging in pretend play. Cooperative play is a key aspect of social development in preschoolers, as it helps them learn social skills, empathy, and teamwork.

This stage is characterized by a shift from parallel play (where children play next to each other but do not interact) to more interactive forms of play. Cooperative play aligns with Erikson’s psychosocial stage of initiative vs. guilt, where children are eager to take on new tasks, explore their environment, and interact socially, developing a sense of purpose and initiative.

Think of cooperative play like building a sandcastle together at the beach. Each child adds their own part to make the sandcastle bigger and better, learning to take turns and work as a team. This shared activity helps them develop important social skills.

Observing children’s play provides insight into their developmental level and psychosocial health. Nurse Megan can support this stage of development by facilitating cooperative play.

• Encourage group activities, such as pretend play or simple group games, to foster social interaction and teamwork.
• Provide toys and resources that encourage shared play, such as building blocks, dolls, or role-playing toys.
• Observe the interactions to ensure positive social behavior and to identify any children who may need additional support with social skills.
• Reinforce positive behaviors, like sharing and turn-taking, to help children feel successful in social interactions.
• Provide feedback to parents about the importance of cooperative play at this stage to support social and emotional growth.

✘Incorrect answer options:

Engaging in competitive board games with older children. Competitive play typically develops in later childhood, as it requires more advanced cognitive and social skills to understand rules, strategy, and the concept of winning and losing. Preschoolers are more focused on interactive and imaginative play rather than competitive play.

Playing independently with their own toys next to other children. This describes parallel play, which is common in toddlers (ages 2-3) but is typically less common by age 4. By this age, children usually start to engage in more interactive forms of play.

Playing solo with handheld computer games. While some children may play alone with electronic devices, it does not reflect the typical social development of a 4-year-old. Preschool-aged children benefit more from interactive, cooperative play that promotes social skill development rather than solitary play with electronics.

EXPLANATION

✔Correct answer:

Auscultate the mass using a stethoscope. When a pulsating mass is observed in the periumbilical area, it raises suspicion of an abdominal aortic aneurysm (AAA). A pulsating mass in this area could indicate the dilation of the abdominal aorta, which can lead to a life-threatening rupture if it grows large enough. The first step in assessing this finding should be to auscultate the area with a stethoscope to check for the presence of a bruit, which is a "whooshing" sound that indicates turbulent blood flow and is often associated with aneurysms.

By auscultating first, Nurse Sarah can gather more information without risking potential harm to the client. Pressing, tapping, or measuring the mass could inadvertently apply pressure to the aneurysm, increasing the risk of rupture, which could be fatal.

Imagine you suspect there’s a balloon with a small leak. Instead of squeezing it to confirm, which might make it burst, you would listen for the sound of escaping air. Similarly, auscultating a suspected aneurysm helps assess the risk without putting pressure on it.

Once Nurse Sarah has auscultated the area, she should proceed with caution and notify the healthcare provider for further evaluation and intervention.

• Auscultate over the mass to listen for any bruits, which could indicate turbulent blood flow and support the suspicion of an aneurysm.
• Avoid palpating or applying pressure to the mass, as this could increase the risk of rupture if it is an aneurysm.
• Document the findings, including the location, size, and any auscultated sounds, to provide clear information for the healthcare provider.
• Alert the healthcare provider immediately to report the finding and request further diagnostic testing, such as an ultrasound or CT scan, if needed.
• Provide reassurance to the client and advise them to avoid any activities that could increase intra-abdominal pressure, as this may elevate the risk of rupture.

✘Incorrect answer options:

Measure the mass to assess its size. Measuring the mass might seem logical in other scenarios, but in the case of a suspected abdominal aortic aneurysm, palpation or pressing on the mass could increase the risk of rupture. Therefore, measuring should be avoided until further diagnostic imaging is performed.

Tap on the mass to evaluate its characteristics. Percussion (tapping) is inappropriate in this case, as it could inadvertently apply pressure to the mass, increasing the risk of rupture if the mass is indeed an aneurysm.

Press on the mass to better assess its consistency. Palpating or pressing on a pulsating mass in the abdomen should be avoided due to the risk of rupturing a potential aneurysm. Pressing could lead to a medical emergency if the aneurysm were to rupture, which could cause severe internal bleeding.

EXPLANATION

✔Correct answer:

Elevated oxidative enzyme levels. Elevated oxidative enzyme levels are not typically associated with adverse medication effects in elderly clients. In fact, elderly clients usually experience reduced oxidative enzyme activity in the liver, specifically in the cytochrome P450 enzyme system, which is responsible for metabolizing many medications. This reduction in enzyme activity can lead to slower drug metabolism, causing medications to remain in the body longer, which increases the risk of toxicity and adverse effects. Reduced enzyme levels are a key reason why elderly patients are more susceptible to drug interactions and side effects.

The other options listed do contribute to undesirable medication effects in older adults:

• Alcohol consumption along with medication can lead to harmful interactions, as alcohol may increase the sedative effects of certain drugs and interfere with drug metabolism.
• Medications that include magnesium, such as certain laxatives and antacids, can cause electrolyte imbalances and gastrointestinal issues in elderly clients, who may already have slower gastrointestinal motility.
• Reduced serum albumin levels are common in elderly individuals and can affect the binding of drugs to proteins, leading to a higher concentration of free (active) drug in the bloodstream, which increases the risk of toxicity.

Imagine the liver’s enzymes as workers in a factory that process medications. In elderly people, the number of workers is reduced, slowing down processing. The medications stay in the system longer, which can lead to accumulation and side effects, unlike in younger adults where they’re processed more quickly.

Nurse Kayla should consider several factors when reviewing medications for elderly clients to prevent adverse effects.

• Assess for any potential drug interactions, especially with over-the-counter medications and alcohol consumption.
• Monitor for signs of toxicity or side effects due to prolonged drug action, especially with drugs metabolized by the liver.
• Be cautious with medications that contain magnesium or other electrolytes, as elderly clients may be more prone to imbalances and gastrointestinal disturbances.
• Consider the client’s serum albumin levels, as low albumin can increase the risk of drug toxicity due to decreased protein binding.
• Educate the client and their family on the importance of avoiding alcohol with certain medications and on recognizing signs of potential adverse effects.

✘Incorrect answer options:

Alcohol consumption along with medication. Alcohol can have dangerous interactions with many medications, particularly in elderly clients who may have slower drug metabolism. Combining alcohol with medication can increase sedation, impair cognitive function, and exacerbate adverse effects, making it a significant risk factor for undesirable medication effects.

Medications that include magnesium. Magnesium-containing medications, such as certain antacids or laxatives, can cause issues in elderly clients. Magnesium can lead to diarrhea, dehydration, and electrolyte imbalances, which can be particularly harmful in older adults due to their decreased kidney function and altered fluid balance.

Reduced serum albumin levels. Low serum albumin levels are common in elderly clients and affect the way drugs bind in the bloodstream. Many drugs bind to albumin, so when albumin levels are low, there is a higher concentration of the unbound (active) form of the drug in circulation, increasing the risk of adverse effects and toxicity.

EXPLANATION

✔Correct answer:

Suggest regular aerobic exercise, such as brisk walking, at least 5 days a week. Regular aerobic exercise is one of the most effective health promotion strategies to reduce the risk of cardiovascular disease. Aerobic activities like brisk walking, jogging, or cycling help lower blood pressure, improve cholesterol levels, enhance circulation, and promote a healthy weight. For adults, the American Heart Association recommends at least 150 minutes of moderate-intensity aerobic exercise per week (or about 30 minutes, 5 days a week). This level of physical activity has been shown to decrease the risk of hypertension, improve heart health, and lower overall cardiovascular risk, especially in individuals with a family history of heart disease.

In this patient’s case, where there is a family history of hypertension and heart disease, prioritizing regular exercise is essential to help him reduce modifiable risk factors, such as weight and blood pressure.

Think of the heart like an engine in a car. Regular exercise is like running the car at optimal speeds, keeping the engine in shape. Just as regular driving helps prevent engine problems, regular aerobic exercise helps keep the heart healthy and reduces the risk of issues down the road.

Nurse should provide additional education and support for the patient to help him adopt and maintain an exercise routine that fits his lifestyle.

• Educate the patient about the benefits of regular exercise, particularly for cardiovascular health, and the specific recommendation of 150 minutes per week.
• Encourage the patient to start slowly if he is not currently active, gradually increasing the duration and intensity of exercise to build endurance safely.
• Discuss other lifestyle factors that support cardiovascular health, such as reducing sodium intake, eating a balanced diet, and managing stress effectively.
• Monitor for any potential contraindications to physical activity and encourage consultation with a healthcare provider before beginning a new exercise program if he has existing health concerns.
• Provide resources on community or online programs that promote heart-healthy activities, such as walking groups or fitness classes.

✘Incorrect answer options:

Recommend reducing daily fluid intake to prevent fluid overload. There is no evidence to suggest that reducing daily fluid intake is an effective strategy to reduce cardiovascular risk for this patient. Fluid restriction is typically indicated only for specific medical conditions, such as heart failure or certain kidney diseases, and not for cardiovascular prevention in a healthy adult.

Encourage a diet high in sodium to maintain electrolyte balance. A diet high in sodium is actually contraindicated for cardiovascular health, as high sodium intake can increase blood pressure, which is a major risk factor for heart disease. Instead, reducing sodium intake is recommended to help prevent hypertension.

Advise the patient to avoid any form of physical activity to reduce stress on the heart. Avoiding physical activity is not recommended and can increase the risk of cardiovascular disease. Regular physical activity is essential for heart health, and avoiding it can lead to weight gain, high blood pressure, and other cardiovascular risks.

EXPLANATION

✔Correct answer:

Fractures involving the epiphyseal plate can disrupt normal growth. In children, the epiphyseal plate (also known as the growth plate) is the area of developing tissue near the ends of long bones. Since the growth plate is responsible for the lengthening of bones during childhood and adolescence, fractures that involve this area can potentially disrupt normal bone growth. Damage to the growth plate can lead to growth disturbances, such as uneven limb length or angulation, if not properly managed. This is particularly concerning in long bones like the femur, where any disruption in growth could lead to noticeable functional and structural issues.

In the case of a growth plate fracture, treatment may require specialized intervention to ensure the bone heals correctly and minimizes the risk of growth abnormalities. Pediatric orthopedic specialists are often involved in these cases to carefully monitor and treat such fractures.

Think of the growth plate like a garden bed where a plant grows. If the bed is disturbed or damaged, the plant’s growth may be stunted or altered. Similarly, a fracture in the growth plate can disrupt a child’s bone development.

Nurse Clara should provide education and support to the family to address concerns about growth and healing.

• Explain the importance of follow-up care with an orthopedic specialist to monitor healing and ensure proper alignment of the growth plate.
• Reassure the family that most fractures in children heal well with appropriate treatment, although careful monitoring is necessary with growth plate involvement.
• Educate the family on the signs of complications, such as uneven limb length or difficulty moving the limb, and stress the importance of reporting these to the healthcare provider.
• Encourage adherence to prescribed treatments, such as casting or physical therapy, which help ensure optimal healing and minimize the risk of growth issues.
• Provide resources on safe mobility and activity restrictions to prevent re-injury during the healing process.

✘Incorrect answer options:

Growth issues arise if the fracture affects the periosteum. The periosteum is a layer of tissue surrounding the bone, which plays a role in bone healing and growth but is not directly responsible for bone lengthening. While it is involved in healing, it is the growth plate (epiphyseal plate) that is critical for longitudinal growth, making periosteal damage less of a concern for growth disruption.

Children heal rapidly, making growth problems uncommon. Although children generally heal faster than adults due to a more robust healing response, fractures involving the growth plate can still result in growth disturbances. Rapid healing does not prevent complications if the growth plate is damaged.

Good blood supply to the bone ensures there won’t be growth delays after fractures. While children do have a good blood supply to their bones, which aids in faster healing, it does not prevent growth disturbances if the fracture affects the growth plate. Blood supply alone cannot mitigate the risk of abnormal growth if the growth plate is injured.

EXPLANATION

✔Correct answer:

Stop the oxytocin infusion immediately. The most appropriate first action when a prolonged late deceleration is observed in the fetal heart rate is to stop the oxytocin (Pitocin) infusion. Oxytocin is used to stimulate contractions, but if contractions are too strong or too frequent, it can reduce blood flow to the placenta, leading to decreased oxygen for the fetus. Late decelerations are a sign of uteroplacental insufficiency, where the fetus is not receiving adequate oxygen during contractions. By stopping the oxytocin, Nurse Kelly can reduce the intensity and frequency of contractions, allowing better blood flow and oxygenation to the fetus.

This is an immediate action that addresses the primary cause of the fetal distress, helping to stabilize the situation and prevent further compromise to fetal oxygenation.

Think of the oxytocin as a gas pedal controlling the speed of a car. If you’re going too fast and start to lose control, the first step is to take your foot off the gas. Stopping the oxytocin is like taking your foot off the gas to slow things down and regain control.

After stopping the oxytocin, Nurse Kelly should take additional steps to further support maternal and fetal well-being.

• Reposition the client to her left side to improve blood flow to the uterus and placenta.
• Administer oxygen via face mask (8-10 L/min) to increase maternal oxygen levels, which can help improve fetal oxygenation.
• Increase the mainline IV fluid rate (usually an isotonic solution like Ringer’s Lactate) to expand maternal blood volume and improve placental perfusion.
• Monitor the fetal heart rate continuously to assess for improvement or persistent signs of fetal distress.
• Notify the healthcare provider immediately to update them on the situation and follow any additional orders.

✘Incorrect answer options:

Reposition the client onto her left side. While repositioning to the left side is a helpful intervention to improve blood flow to the uterus, it is not the first priority in this case. The immediate action should be to stop the oxytocin infusion, as this directly addresses the cause of the excessive contractions contributing to late decelerations.

Switch the IV fluid to Ringer’s Lactate. Switching to Ringer’s Lactate or increasing the IV fluid rate may help improve placental perfusion, but it does not address the immediate issue of excessive contractions caused by oxytocin. Stopping the oxytocin is a more direct response to the fetal heart rate deceleration.

Increase the mainline IV fluid rate. Increasing the IV fluid rate can be beneficial for maternal and fetal circulation, but it is not the first intervention. Stopping the oxytocin takes precedence as it directly addresses the contraction frequency and intensity, which is contributing to the fetal heart rate deceleration.

EXPLANATION

✔Correct answer:

A head circumference measuring 40 cm. In a newborn, the typical head circumference is around 32-36 cm. A measurement of 40 cm is significantly larger than average and may indicate macrocephaly or increased intracranial pressure. This finding could be associated with conditions such as hydrocephalus (excess fluid in the brain) or other congenital anomalies. Nurse Jenny should report this finding to the physician promptly for further evaluation, as it may require imaging studies (like an ultrasound or MRI) to rule out any serious underlying condition.

In newborn assessments, it is critical to evaluate head size closely because it provides early clues about possible neurological conditions or abnormalities in brain development. Reporting an unusually large head circumference ensures early intervention and appropriate care.

Think of head circumference as the “frame” around the newborn’s brain. If the frame is too large, it might suggest an issue with how the brain or skull is developing, just like a picture frame that doesn’t match the picture could signal something is off.

Along with notifying the physician, Nurse Jenny should consider the following actions.

• Measure the head circumference again to confirm accuracy and rule out any measurement error.
• Assess for other signs of increased intracranial pressure, such as bulging fontanelles, poor feeding, or lethargy.
• Document the head circumference along with any other pertinent findings, such as unusual head shape or asymmetry.
• Prepare to assist with further diagnostic testing, such as an ultrasound if ordered by the physician.
• Provide education and reassurance to the parents, explaining that additional assessment is necessary to ensure the baby’s well-being.

✘Incorrect answer options:

A chest circumference measuring 32 cm. A newborn’s chest circumference is typically 1-2 cm smaller than the head circumference. A chest measurement of 32 cm is within the normal range and would not be cause for concern in this case.

Bluish hands and feet with some scalp edema. Bluish hands and feet (acrocyanosis) are common in newborns as they adjust to extrauterine life. Scalp edema (caput succedaneum) can occur due to pressure on the head during delivery and generally resolves on its own. These findings are considered normal for a newborn and do not require reporting.

A heart rate of 160 beats per minute and 40 breaths per minute. These are normal vital signs for a newborn. A heart rate between 120-160 bpm and a respiratory rate of 30-60 breaths per minute are typical for healthy newborns. Therefore, these findings do not need to be reported.

EXPLANATION

✔Correct answer:

Explain to the client that dentures must be removed to prevent airway obstruction. The most appropriate action is for Nurse Emma to explain to the client why removing the dentures is necessary. Under general anesthesia, the client will lose muscle tone, which includes the muscles of the mouth and throat. If dentures are left in, they pose a significant risk of becoming dislodged and blocking the airway, which could lead to serious complications such as aspiration or airway obstruction. Providing a clear explanation helps the client understand the rationale behind the requirement, which may reduce resistance and promote cooperation.

Effective communication is essential in this situation to address any concerns the client may have and ensure that they feel respected and informed. By focusing on patient safety and providing reassurance, Nurse Emma can help the client feel more comfortable with the decision to remove the dentures.

Think of dentures like wearing loose jewelry during a high-speed ride. Just as loose items could fall off and create a hazard, dentures can shift in a relaxed mouth and obstruct breathing during surgery. Removing them is a precaution to ensure safety.

Nurse Emma should consider additional strategies to help the client feel comfortable and safe about removing dentures before surgery.

• Provide a clear, gentle explanation emphasizing that removing dentures is a routine safety measure for all patients undergoing general anesthesia.
• Offer a safe storage solution, such as a labeled denture cup, to reassure the client that their dentures will be kept secure and returned after surgery.
• Address any questions or concerns the client has regarding discomfort or self-consciousness without their dentures, and validate their feelings.
• Document the client’s consent to remove the dentures and any additional instructions or preferences expressed by the client regarding post-operative care of the dentures.
• Ensure the surgical team is aware that the dentures have been removed, as this is part of the preoperative checklist for safety and continuity of care.

✘Incorrect answer options:

Allow the client to keep the dentures in for comfort during transport. This option is unsafe, as it does not address the risk of airway obstruction. The dentures should be removed before entering the operating room, as delaying removal can lead to a greater risk of complications once anesthesia is administered.

Notify the surgeon that the client refuses to remove the dentures. Although notifying the surgeon may be appropriate if the client remains resistant, it should not be the first action. Nurse Emma should first attempt to explain the importance of removing the dentures and address any concerns the client has.

Remove the dentures once the client is sedated in the operating room. Removing dentures after the client is sedated is unsafe and impractical. Once sedated, the client’s muscle tone will be reduced, which increases the risk of dislodging the dentures during transport or the beginning stages of anesthesia. Dentures should always be removed prior to sedation for safety.