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A 29-year-old low-risk primiparous patient has just placental abruption?
- A. Mild: Grade 1
- B. Moderate: Grade 2
- C. Marked: Grade 3
- D. Severe: Grade 4
Correct Answer: B
Rationale: Placental abruption is classified based on the severity of symptoms and extent of separation of the placenta from the uterine wall. In a low-risk primiparous patient like the one described, a moderate placental abruption (Grade 2) is likely when there is some vaginal bleeding, mild to moderate abdominal pain, and signs of fetal distress such as abnormal fetal heart rate patterns.
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A nurse is assessing a client following an amniocentesis. Which of the following findings should the nurse recognize as complications? (Select all that apply).
- A. Amnionitis
- B. Urinary tract infection
- C. Polyhydramnios
- D. Leakage of amniotic fluid
Correct Answer: A
Rationale: A. Amnionitis: This is the inflammation of the amniotic sac or membranes and is a potential complication following an amniocentesis procedure. It can lead to maternal fever, fetal tachycardia, and other signs of infection.
Which signs/symptoms would the nurse expect to see in a client diagnosed with pubic lice?
- A. Macular rash on the labia.
- B. Pruritus.
- C. Hyperthermia.
- D. Foul-smelling discharge.
Correct Answer: B
Rationale: Itching (pruritus) is a hallmark symptom of pubic lice infestation.
The nurse is administering a number of therapeutic interventions for neonates, infants, and children on the pediatric unit. Which intervention contributes to an increase in chronic illness seen in early childhood?
- A. Administering antibiotics to prevent lethal infections
- B. Vaccinating children to prevent childhood diseases
- C. Using mechanical ventilation for premature infants
- D. Using corticosteroids as a treatment for asthma
Correct Answer: C
Rationale: Using mechanical ventilation and medications to foster lung development in premature infants increases their survival rate. Yet the infants who survive are often faced with myriad chronic illnesses.
A newborn is delivered vaginally in the breech presentation. When examining her baby, the mother asks if the baby has been injured during birth because of the large black and blue areas on the buttocks and legs, The nurse should respond that:
- A. This is not a birth injury probably just a birthmark
- B. These are caused by forceps used to aid in the delivery of the baby
- C. This a temporary complication that will disappear in about a week
- D. These Mongolian spots, common in dark-skinned babies, disappear within a year
Correct Answer: C
Rationale: Bruising from breech delivery is temporary.
What actions should the nurse advise women to take when educating them on breast self-examination (BSE)?
- A. Use the fingertips of their index, middle, and ring fingers.
- B. Use pressure in two intensities, light and deep.
- C. Look for dimpling while bending forward from the waist.
- D. Feel for lumps while encircling the breast from nipple outward.
Correct Answer: A
Rationale: Proper technique ensures accurate detection of abnormalities.