Which statement by newborn parents does not indicate a need for further teaching about cord care?

Correct Answer: D

Rationale: Correct Answer: D Rationale: 1. Washing hands before and after cord care is a standard hygiene practice to prevent infection. 2. Options A and B are incorrect as alcohol and covering the cord can lead to complications. 3. Option C suggests recognizing concerning changes in the cord, indicating good understanding. 4. Thus, option D is correct as it is a crucial step in cord care and does not indicate a need for further teaching.

Correct Answer: A

Rationale: The correct answer is A: Administer oxygen. The first action should be to ensure the client's oxygenation as chest pain could indicate decreased oxygen supply. Administering oxygen helps improve oxygen levels and can be crucial in managing potential complications. Summary of other choices: B: Administering morphine may mask the pain but doesn't address the underlying issue. C: Administering anticoagulants is not appropriate as the cause of chest pain is not related to clotting. D: Applying a warm compress is not indicated and may delay proper assessment and intervention for the chest pain.

Correct Answer: A

Rationale: The correct answer is A because the dull sound over the ribs is a normal finding due to the presence of underlying solid structures such as the liver or spleen. Repositioning the hands or using more force is unnecessary as it won't change the nature of the sound. Referring the patient for additional investigation (choice D) is not warranted as this finding is commonly expected during percussion over the ribs.

Correct Answer: A

Rationale: The correct answer is A because as a nurse, it is essential to respect and accommodate the cultural beliefs and preferences of patients. By offering to assist in arranging for the presence of the medicine woman, the nurse shows empathy, cultural competence, and patient-centered care. This approach promotes trust, communication, and collaboration with the patient. Choice B is incorrect as it disregards the patient's request and shows a lack of respect for their beliefs. Choice C is incorrect as it dismisses the significance of the patient's request, which can impact the therapeutic relationship. Choice D is incorrect as it invalidates the patient's beliefs and cultural practices, which can lead to feelings of disrespect and lack of trust.

Correct Answer: A

Rationale: The correct answer is A: Perform a lumbar puncture. This is the first action because diagnosing meningitis requires cerebrospinal fluid analysis obtained through a lumbar puncture. It helps identify the specific type of meningitis (bacterial, viral, or fungal) and guides appropriate treatment. Administering pain relief (B) or oxygen (C) may be necessary but not the initial priority. Administering antibiotics (D) should be based on the results of the lumbar puncture to ensure targeted therapy.

Correct Answer: B

Rationale: The correct answer is B: Administer antibiotics. In sepsis, timely administration of antibiotics is crucial to combat the underlying infection. Antibiotics target the bacteria causing the sepsis, helping to prevent further spread and worsening of the condition. Administering IV fluids (choice A) is important to maintain blood pressure, but antibiotics take precedence in treating the infection. Providing fluids (choice C) is also important but not the priority over antibiotics. Administering oxygen (choice D) may be necessary for respiratory support in severe cases of sepsis, but it does not address the root cause of the condition like antibiotics do.

Correct Answer: A

Rationale: The correct answer is A: Administer IV fluids. The initial priority in managing sepsis is to restore perfusion and oxygenation by giving IV fluids to support blood pressure and organ perfusion. This helps to improve tissue oxygenation and prevents further organ damage. Administering insulin (choice B) is not the priority in the initial management of sepsis. Monitoring blood pressure (choice C) is important but not the first step in the management of sepsis. Administering insulin is also listed twice and is not relevant to the immediate management of sepsis.

Correct Answer: A

Rationale: The correct answer is A: Administer aspirin. Aspirin helps prevent further clot formation by inhibiting platelet aggregation, reducing the risk of additional heart damage. It is a standard treatment in acute myocardial infarction. Administering morphine (B) may be considered for pain relief but is not the primary intervention. Monitoring vital signs (C) is important, but not the primary intervention. Administering fibrinolytics (D) is indicated in certain cases but is not the primary intervention and requires specific criteria and caution.

Correct Answer: A

Rationale: Step 1: Cirrhosis can impair the liver's ability to store glycogen and produce glucose. Step 2: Liver dysfunction can lead to hypoglycemia due to decreased glycogen stores and gluconeogenesis. Step 3: Monitoring for hypoglycemia is crucial as it can result in serious complications. Step 4: Hyperglycemia (B) is less likely in cirrhosis as the liver's ability to regulate blood sugar is impaired. Step 5: Hypokalemia (C) and hyperkalemia (D) are less directly related to cirrhosis and are not the primary concerns in this case.