The nurse is teaching parents of a newborn about feeding their infant. Which instruction should the nurse include?

Correct Answer: A

Rationale: Rationale for Correct Answer A: 1. Using the defrost setting on microwave ovens to warm bottles is safe because it ensures even heating without creating hot spots that could burn the baby's mouth. 2. This method helps to preserve the nutrients in the breast milk or formula. 3. It is important to warm the bottle to body temperature to mimic the natural feel of breast milk for the baby's comfort. Summary of Incorrect Choices: B: Feeding the baby partially used bottles after 24 hours can increase the risk of bacterial contamination and foodborne illness. C: Mixing two parts water and one part concentrate for formula concentrate is incorrect as it may dilute the formula, leading to inadequate nutrition for the baby. D: Adding new formula to partially used bottles can alter the balance of nutrients and increase the risk of contamination, affecting the baby's health.

Correct Answer: B

Rationale: The correct answer is B: Deep vein thrombosis (DVT). Patients with a history of stroke are at increased risk for DVT due to immobility and potential damage to blood vessels. The nurse should monitor for signs such as swelling, pain, and redness in the extremities. Pneumonia (A) can occur post-stroke but is not the most common complication. Hypoglycemia (C) is more relevant for diabetic patients. Hypertension (D) is a common comorbidity in stroke patients but monitoring for DVT is crucial due to its immediate life-threatening implications.

Correct Answer: A

Rationale: The correct answer is A: Immobilize the client. This is crucial to prevent further damage to the spinal cord. Moving a client with a suspected spinal cord injury can worsen the injury and lead to permanent damage. Immobilizing the client helps maintain spinal alignment and reduces the risk of paralysis. Providing pain relief (B) and loosening clothing (D) are important but secondary actions. Applying pressure to the chest (C) is not recommended for a suspected spinal cord injury as it can also exacerbate the injury.

Correct Answer: C

Rationale: Step 1: Nutrition is important for healing and energy. Step 2: Elimination is crucial for bowel and bladder function. Step 3: Comfort ensures the client's well-being. Step 4: Safety prevents complications. Step 5: ROM exercises can prevent muscle atrophy. Step 6: Transportation and isotonic exercises are not immediate priorities.

Correct Answer: C

Rationale: The correct answer is C: Diagnostic hypothesis. Nurses use diagnostic reasoning to formulate diagnostic hypotheses based on patient data and clinical judgment. They analyze symptoms and data to generate potential diagnoses. Choice A, nursing diagnosis, involves identifying patient problems related to nursing care. Choice B, medical diagnosis, is made by physicians to identify diseases or medical conditions. Choice D, diagnostic assessment, refers to the process of collecting and analyzing data to make a diagnosis. Diagnostic hypothesis aligns with the process of diagnostic reasoning in nursing practice.

Correct Answer: A

Rationale: The correct answer is A: Inspecting feet daily for signs of injury. This is crucial for patients with diabetes and peripheral neuropathy to prevent complications like infections and ulcers. By inspecting their feet daily, the patient can identify any injuries or abnormalities early and seek prompt medical attention. This proactive approach can help prevent serious consequences such as amputations. Summary of incorrect choices: B: Taking medications only when experiencing symptoms - This is not recommended as medications for diabetes and neuropathy are often prescribed to prevent complications and manage the conditions on a daily basis. C: Exercising to increase foot circulation - While exercise is beneficial, patients with peripheral neuropathy may have decreased sensation in their feet, increasing the risk of injury during exercise. D: Wearing tight-fitting shoes to avoid blisters - Tight-fitting shoes can cause pressure points and increase the risk of foot injuries, especially in patients with neuropathy.

Correct Answer: A

Rationale: The correct answer is A: Apply a sterile dressing. Firstly, cover the wound with a sterile occlusive dressing to prevent air from entering the pleural space, reducing the risk of tension pneumothorax. This also helps to prevent infection and further complications. Administering morphine (B) or nitroglycerin (D) is not the priority in this situation as managing the chest wound is crucial. Applying an airtight dressing (C) may lead to tension pneumothorax if not done properly. Therefore, the immediate action should be to apply a sterile dressing to stabilize the wound and prevent further complications.

Correct Answer: A

Rationale: The correct answer is A: Orthostatic hypotension. In a patient with congestive heart failure, there is impaired cardiac function leading to decreased cardiac output. This can result in orthostatic hypotension, where blood pressure drops upon standing. Monitoring for orthostatic hypotension is important to prevent falls and other complications. B: Hyperkalemia is not typically associated with congestive heart failure. C: Hypoglycemia may occur in patients with diabetes, but it is not a common complication of congestive heart failure. D: Severe dehydration is not directly related to congestive heart failure unless the patient has concurrent issues such as diarrhea or excessive diuresis.

Correct Answer: D

Rationale: The correct answer is D: Administer corticosteroids. In a client with chest pain and a history of myocardial infarction, the first priority is to address potential inflammation in the myocardium. Corticosteroids help reduce inflammation and stabilize the myocardium, which is crucial in preventing further damage post-myocardial infarction. Administering nitroglycerin (A) is important for vasodilation, but it is typically used after corticosteroids. Morphine (B) and analgesics (C) may provide pain relief but do not address the underlying inflammation. Administering corticosteroids is the most appropriate first step to manage myocardial inflammation and protect the heart tissue.