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A nurse is caring for a client who is postoperative following a mastectomy. The client expresses concern that they will no longer be attractive to their partner. Which of the following actions should the nurse take?
- A. Discourage the client from looking at their breasts.
- B. Recommend a support group for the client to attend.
- C. Tell the client you are so sorry for how devastated they must feel.
- D. Tell the client to focus on their postoperative recovery for now.
Correct Answer: B
Rationale: Recommending a support group provides psychosocial support, enabling clients to share experiences and gain insights from peers, which can alleviate feelings of inadequacy and encourage acceptance of body image changes.
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A nurse is caring for a client who is in active labor. The nurse notes early decelerations of the FHR on the fetal monitor tracing. The nurse should identify that which of the following conditions causes early decelerations in the FHR?
- A. Fetal hypoxemia.
- B. Uteroplacental insufficiency.
- C. Cord compression.
- D. Head compression.
Correct Answer: D
Rationale: Early decelerations result from fetal head compression, stimulating the vagus nerve and leading to transient heart rate decreases. This is common during contractions.
For each body system below, specify the potential manifestations that the client may experience. Match each body system with the potential manifestation.
- A. Nausea
- B. Pain
- C. Headache
- D. Body aches
Correct Answer: D
Rationale: General: Body aches (D) - reflects systemic discomfort. Head, ears, eyes, nose, and throat: Headache (C) - common neurological symptom. Gastrointestinal: Nausea (A) - due to digestive disturbances. Breast: Pain (B) - related to tissue sensitivity or engorgement.
A client reports an intermittent dark brown vaginal discharge for the past three days. What should the nurse do?
- A. The nurse should assess the client for signs of molar pregnancy.
- B. The nurse should evaluate the risk for hypovolemic shock due to blood loss.
- C. The nurse should ensure appropriate laboratory testing for the diagnosis of choriocarcinoma.
- D. The nurse should prioritize preparing the client for suction and curettage.
Correct Answer: A
Rationale: Molar pregnancy often manifests as intermittent dark brown vaginal discharge due to trophoblastic tissue expulsion. It warrants assessment as it correlates with hCG elevation and abnormal placental development.
A nurse is assessing a newborn who is 48 hr old and is experiencing opioid withdrawals. Which of the following findings should the nurse expect?
- A. Hypotonicity.
- B. Moderate tremors of the extremities.
- C. Axillary temperature 36.1°C (96.9° F).
- D. Excessive sleeping.
Correct Answer: B
Rationale: Moderate tremors result from central nervous system irritability during withdrawal. Elevated norepinephrine levels lead to excessive stimulation, causing tremors and jitteriness.
A nurse is reviewing the laboratory results of a newborn who is 32 hours old and has a cephalohematoma. Which of the following findings should the nurse expect as a result of this condition?
- A. WBC count of 35,000/mm² (normal range: 9,000 to 30,000/mm²).
- B. Glucose level of 35 mg/dL (normal range: greater than 40 to 45 mg/dL).
- C. Bilirubin level of 14.0 mg/dL (normal range: 1.0 to 12.0 mg/dL).
- D. Platelet count of 350,000/mm³ (normal range: 150,000 to 300,000/mm³).
Correct Answer: C
Rationale: A bilirubin level of 14.0 mg/dL is above the newborn normal range of 1.0 to 12.0 mg/dL. This indicates hyperbilirubinemia, commonly seen due to red blood cell breakdown in cephalohematoma.