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A nurse is assessing a client who is at 27 weeks of gestation and has preeclampsia. Which of the following findings should the nurse report to the provider?
- A. Urine protein concentration 200 mg/ 24 hr.
- B. Creatinine 0.8 mg/ Dl
- C. Hemoglobin 14.8 g/ dL
- D. Platelet Count 60.000/ mm3
Correct Answer: D
Rationale: A platelet count of 60,000/mm3 is significantly low and can be indicative of thrombocytopenia, a potential complication of preeclampsia known as HELLP syndrome (Hemolysis, Elevated Liver enzymes, and Low Platelet count). Thrombocytopenia increases the risk of bleeding complications during pregnancy and delivery, requiring prompt evaluation and management by the healthcare provider. The nurse should report this finding immediately to prevent any adverse outcomes for the client and baby.
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The nurse is working with a group of community health members to develop a plan to address the special health needs of women. Which educational program would the group most likely identify as the priority?
- A. risk reduction strategies for diabetes
- B. methods for smoking cessation
- C. ways to adopt a heart-healthy lifestyle
- D. importance of cancer screening and early detection
Correct Answer: C
Rationale: The group needs to address cardiovascular disease, the number one cause of death in women regardless of racial or ethnic group. Thus, education for adopting a heart-healthy lifestyle would be the priority.
When teaching a parenting class on childhood discipline, the nurse is asked by a parent, 'How long do I place my child in time-out?' How should the nurse best respond?
- A. Use the amount of time it takes to elicit a behavior change.
- B. Use 1 minute per year of age, but do not exceed 5 minutes.
- C. Use as much time as is needed to control the behavior.
- D. Use 1 minute per year of the child's age as needed.
Correct Answer: B
Rationale: When using time-out, use 1 minute per year of the child's age (a 3-year-old would have time-out for 3 minutes). Do not exceed 5 minutes.
A client at 34 weeks' gestation is diagnosed with polyhydramnios. What complication should the nurse monitor for?
- A. Preterm labor.
- B. Placental abruption.
- C. Fetal growth restriction.
- D. Cord prolapse.
Correct Answer: A
Rationale: Polyhydramnios increases the risk of preterm labor due to uterine overdistension.
The nurse notes that an older adult client receives only one visitor and asks the client if family members could be called. The client states, 'I consider her to be all of my family.' What would the nurse consider in responding to the client?
- A. The nurse could encourage the client to reconnect with other family members.
- B. The client defines who is and who is not part of the family without undue influence.
- C. The nurse realizes individuals exist without a family and do not often adopt substitutes.
- D. Family is more important to those individuals with a large number of family members.
Correct Answer: B
Rationale: It is important for nurses to remain neutral to all they hear and see in order to enhance trust and maintain open communication lines with all family members. Nurses need to remember that clients are experts of their own health and can define their own family.
To maximize absorption, what supplement should a client take with calcium?
- A. Vitamin D.
- B. Vitamin E.
- C. Folic acid.
- D. Iron.
Correct Answer: A
Rationale: Vitamin D enhances calcium absorption.