A client at 9-weeks gestation informs the nurse that she has reduced her alcohol intake but still consumes at least one alcoholic drink every evening before bedtime.
What action should the nurse take?

Praise the client for her actions and offer to discuss ways to decrease consumption even more.

Insist that the client stop all alcohol use and draw a blood alcohol level at each prenatal visit.

Notify child protective services of the client’s illicit drug use and probable child endangerment.

Refer the client to an outpatient alcohol abuse program for disulfiram therapy.

Answer and Explanation

The Correct Answer is A

The correct answer is A. Praise the client for her actions and offer to discuss ways to decrease consumption even more.

Why? During pregnancy, any amount of alcohol poses a risk to the developing fetus, but abruptly shaming or forcing action may not be effective. The best approach is motivational interviewing, which involves acknowledging the client's reduction while encouraging further progress. A supportive conversation can help guide the client toward complete cessation of alcohol use.

Here’s why the other options are incorrect:

B. Insist that the client stop all alcohol use and draw a blood alcohol level at each prenatal visit – While alcohol cessation is the goal, forcing the client without a supportive approach can lead to resistance. Routine blood alcohol testing is not standard unless substance dependence is suspected.
C. Notify child protective services of the client’s illicit drug use and probable child endangerment – Alcohol is not classified as an illicit drug, and reporting at this stage would be premature unless clear evidence of abuse or harm to the fetus exists.
D. Refer the client to an outpatient alcohol abuse program for disulfiram therapy – Disulfiram (Antabuse) is not recommended in pregnancy, as it may cause adverse effects. Instead, behavioral counseling and support groups are preferred interventions.

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Correct Answer is C

Explanation

Choice A rationale

Keeping the skin incision moist by periodically wetting the dressing is not the recommended care for a myelomeningocele surgical repair. The dressing needs to be kept dry to prevent infection and promote healing.

Choice B rationale

Removing the tape rapidly from the edges of the dressing during a change is not advised. This could potentially damage the skin and disrupt the healing process.

Choice C rationale

An intact dressing protects the incision from fecal contamination, which is crucial in preventing infection. This statement indicates an understanding of the procedure.

Choice D rationale

While it’s important to keep the dressing dry to ensure easy removal of sutures, it’s not the primary concern. The main goal is to protect the incision from contamination.

A. Manual resuscitation bag B. An advanced airway kit C. A dose of subcutaneous epinephrine D. The child’s favorite toy E. Nebulized albuterol

Correct Answer is B

Explanation

The correct answer is choice A. Manual resuscitation bag and B. An advanced airway kit.

Choice A rationale:

A manual resuscitation bag is essential in pediatric emergencies to provide immediate ventilation support if the child experiences respiratory failure or arrest. This device allows healthcare providers to manually deliver breaths to the patient, ensuring adequate oxygenation and ventilation until more advanced airway management can be established.

Choice B rationale:

An advanced airway kit is crucial for managing a difficult airway, especially in pediatric patients who may have anatomical differences making intubation challenging. This kit typically includes tools for endotracheal intubation, laryngeal mask airways, and other devices to secure the airway and ensure the child can breathe effectively.

Choice C rationale:

A dose of subcutaneous epinephrine is primarily used for treating severe allergic reactions or anaphylaxis. While it is a critical medication in emergencies involving anaphylaxis, it is not directly related to the immediate need for airway management and ventilation in this scenario.

Choice D rationale:

The child’s favorite toy can be helpful in calming and distracting the child during medical procedures, reducing anxiety and making the experience less traumatic. However, it is not a medical necessity for the placement of an intravenous line or for managing respiratory distress.

Choice E rationale:

Nebulized albuterol is used to treat bronchospasm and wheezing, commonly seen in asthma or reactive airway disease. While it is an important medication for managing respiratory symptoms, it does not address the immediate need for airway management and ventilation support in a critical situation.

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A client at 9-weeks gestation informs the nurse that she has reduced her alcohol intake but still consumes at least one alcoholic drink every evening before bedtime. What action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is instructing the parents of a child who underwent a surgical repair of a myelomeningocele on how to change an occlusive dressing on the child’s back. Which parental statement indicates understanding of the procedure?

Correct Answer is C

Explanation

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

Correct Answer is B

Explanation

Choice A rationale:

Choice B rationale:

Choice C rationale:

Choice D rationale:

Choice E rationale:

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A client at 9-weeks gestation informs the nurse that she has reduced her alcohol intake but still consumes at least one alcoholic drink every evening before bedtime.
What action should the nurse take?