Extract:

Client for a local health fair about breast self-examination (BSE)

Question 1 of 5

A community health nurse is developing a pamphlet about breast self-examination (BSE) for a local health fair. Which of the following instructions should the nurse include?

A. Expect some breast dimpling or discharge with age.B. Using the palm of the hand, feel for lumps using a circular motion.C. Breasts can be examined in the shower with soapy hands.D. For those who have a menstrual cycle, perform a BSE every month, 2 or 3 days before menstruation.

Correct Answer: C

Rationale: Examining breasts in the shower with soapy hands facilitates smooth gliding of fingers, making it easier to detect lumps or changes.

Extract:

Child admitted with suspected rheumatic fever

Question 2 of 5

A nurse is caring for a child who was admitted with suspected rheumatic fever. The provider prescribes an anti-streptolysin O (ASO) titer. The parent asks the nurse the purpose of the test. What should the nurse respond?

A. This test will indicate if your child has rheumatic fever.B. This test will confirm if your child had a recent streptococcal infection.C. This test will indicate if your child has a therapeutic blood level of an aminoglycoside.D. This test will confirm if your child has immunity to streptococcal bacteria.

Correct Answer: B

Rationale: An ASO titer confirms recent streptococcal infection, a precursor to rheumatic fever, by detecting streptolysin O antibodies.

Extract:

Client at 36 weeks gestation who has just delivered a stillborn baby

Question 3 of 5

A client at 36 weeks gestation has just delivered a stillborn baby. What should the nurse say?

A. You may hold your baby as long as you want.B. This is for the best. Your baby was very ill.C. I understand your grief. I lost a baby also.D. I have called for the chaplain to come and stay with you.

Correct Answer: A

Rationale: Offering to hold the stillborn baby supports the grieving process, allowing acknowledgment of the loss.

Extract:

Patient in preterm labor at 32 weeks of gestation

Question 4 of 5

A nurse is attending to a patient who is in preterm labor at 32 weeks of gestation. The patient asks the nurse, 'Will my baby be okay?' What should the nurse respond?

A. We have a neonatal unit here that's equipped to handle emergencies.B. Everyone worries about their baby when they're in labor.C. You must be feeling scared and powerless.D. Your pregnancy is advanced so your baby should be fine.

Correct Answer: A

Rationale: Reassuring the patient about the hospital's neonatal unit capabilities directly addresses concerns about the baby's care.

Extract:

Newborn baby boy with vital signs at 1 minute: Heart rate- 160 bpm, Respiratory effort - good, crying vigorously, Muscle tone - active movement, well flexed, Reflex irritability - cries with stimulation of soles of feet, Color - body pink, feet and hands cyanotic