Nokea
Click to specify which of the following actions the nurse should anticipate including in the client's plan of care. Select all that apply.
- A. Monitor blood pressure.
- B. Initiate contact precautions.
- C. Prepare for amniocentesis .
- D. Apply internal fecal monitor.
- E. Decrease lighting in the client's room
- F. Check urinary output.
- G. Encourage bed rest.
Correct Answer: A,C,G
Rationale: Reposition the client (Trendelenburg or knee-chest)
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A nurse is caring for a client who is at 36 weeks of gestation and has methicillin-resistant Staphylococcus aureus. Which of the following types of isolation precautions should the nurse initiate?
- A. Droplet
- B. Contact
- C. Protective environment
- D. Airborne
Correct Answer: B
Rationale: The correct answer is B: Contact precautions. Methicillin-resistant Staphylococcus aureus (MRSA) is primarily spread through direct contact with infected individuals or contaminated surfaces. Therefore, the nurse should initiate contact precautions to prevent the spread of MRSA to others. Droplet precautions (choice A) are used for diseases transmitted via respiratory droplets, such as influenza. Protective environment (choice C) is used for immunocompromised clients to protect them from environmental pathogens. Airborne precautions (choice D) are for diseases transmitted via small droplet nuclei, like tuberculosis. No other choices are applicable for MRSA.
Which of the following is a potential complication of a forceps-assisted delivery?
- A. Shoulder dystocia
- B. Hemorrhage
- C. Birth trauma
- D. All of the above
Correct Answer: C
Rationale: The correct answer is C: Birth trauma. Forceps-assisted delivery can result in birth trauma due to the application of forceps on the baby's head, leading to injuries such as facial bruising or lacerations. Shoulder dystocia (choice A) is a complication during natural delivery, not specific to forceps. Hemorrhage (choice B) can occur post-delivery and is not directly related to forceps. Choice D is incorrect as not all complications listed are directly associated with forceps-assisted delivery.
Which of the following is a potential complication of neonatal hypocalcemia?
- A. Hyperglycemia
- B. Hypoglycemia
- C. Hypotension
- D. All of the above
Correct Answer: C
Rationale: Neonatal hypocalcemia can lead to hypotension due to low calcium levels.
A nurse is assessing a client who is 3 days postpartum. Which of the following findings should the nurse report to the provider?
- A. Cool, clammy skin
- B. Moderate lochia serosa
- C. Heart rate 89/min
- D. BP 120/70 mm Hg
Correct Answer: A
Rationale: The correct answer is A: Cool, clammy skin. This finding could indicate hypovolemic shock, a serious complication postpartum. The nurse should report this to the provider immediately for further assessment and intervention. Choice B, moderate lochia serosa, is a normal finding 3 days postpartum. Choice C, heart rate 89/min, and choice D, BP 120/70 mm Hg, are within normal limits for a postpartum client and do not require immediate reporting.
Which of the following hormones stimulates ovulation?
- A. Progesterone
- B. Estrogen
- C. Luteinizing hormone (LH)
- D. Follicle-stimulating hormone (FSH)
Correct Answer: C
Rationale: Luteinizing hormone (LH) is responsible for triggering ovulation by stimulating the release of an egg from the ovary. This is a key part of the menstrual cycle.