Nokea
A nurse is planning a presentation about HIV for a church-based group. Which of the following information about HIV transmission should the nurse include?
- A. It is primarily transmitted through mosquitoes.
- B. It is primarily transmitted through accidental puncture wounds.
- C. It is primarily transmitted through sexual contact.
- D. It is primarily transmitted through respiratory droplets.
Correct Answer: C
Rationale: HIV is primarily transmitted through sexual contact involving infected fluids like semen or vaginal secretions. Mosquitoes, respiratory droplets, and puncture wounds (rare) don't commonly spread HIV.
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A pregnant woman undergoes a triple/quadruple screen at 16 to 18 weeks' gestation. What would the nurse suspect if the woman's alpha-fetoprotein (AFP) level is decreased?
- A. Sickle-cell anemia
- B. Cardiac defects
- C. Down syndrome
- D. Respiratory disorders
Correct Answer: C
Rationale: Low AFP suggests Down syndrome, often with altered hCG and estriol. Sickle-cell anemia uses other tests, cardiac defects may raise AFP, and respiratory issues don't typically affect AFP levels.
A nurse is assessing a client who may be pregnant. The nurse reviews the client's history for presumptive signs. Which signs would the nurse most likely note? Select all that apply.
- A. Nausea
- B. Abdominal enlargement
- C. Positive pregnancy test
- D. Braxton Hicks contractions
- E. Amenorrhea
Correct Answer: A,B,C,E
Rationale: Presumptive signs, subjective or non-definitive, include nausea (hormonal), abdominal enlargement (uterine growth), positive pregnancy test (hCG detection), and amenorrhea (missed periods). Braxton Hicks are probable signs, felt later.
A nurse is providing teaching about nutrition to a client at her first prenatal visit. Which of the following statements by the nurse should be included in the teaching?
- A. Vitamin E requirements decrease during pregnancy due to the increase in body fat.
- B. Prenatal vitamins will meet your need for increased folic acid during pregnancy.
- C. You will need to double your intake of protein during pregnancy.
- D. You will need to increase your intake of calcium during pregnancy.
Correct Answer: B
Rationale: Prenatal vitamins provide 600 mcg/day folic acid, meeting pregnancy needs to prevent neural tube defects. Vitamin E needs remain at 15 mg/day, protein increases slightly to 1.1 g/kg/day (not doubled), and calcium needs stay at 1000 mg/day due to enhanced absorption, not requiring an increase.
Upon entering the room of a client who has had a spontaneous abortion, the nurse observes the client crying. Which response by the nurse would be most appropriate?
- A. I'm sorry you lost your baby.
- B. Why are you crying?
- C. Will a pill help your pain?
- D. A baby still wasn't formed in your womb.
Correct Answer: A
Rationale: Saying 'I'm sorry you lost your baby' acknowledges the client's emotional loss empathetically. Asking why she's crying invalidates her feelings, focusing on physical pain ignores emotional needs, and claiming the baby wasn't formed is inaccurate and insensitive, as miscarriage involves loss at any stage.
It is determined that a client's blood Rh is negative and her partner's is positive. To help prevent Rh isoimmunization, the nurse would expect to administer Rho(D) immune globulin at which time?
- A. 24 hours before delivery and 24 hours after delivery
- B. In the first trimester and within 2 hours of delivery
- C. At 28 weeks gestation and again within 72 hours after delivery
- D. At 32 weeks gestation and immediately before discharge
Correct Answer: C
Rationale: Rho(D) immune globulin at 28 weeks and within 72 hours post-delivery prevents Rh isoimmunization effectively. Other schedules miss critical windows for blocking maternal antibody response.