Nokea
A 16-year-old client at 34 weeks' gestation, who is being monitored at home with home nursing visits, is diagnosed with mild preeclampsia and has gained 2 lb in the past week. Her current blood pressure is 144/92 mm Hg. Which assessment finding would require further action by the home health nurse?
- A. Occasional headache.
- B. Frequent voiding in large amounts.
- C. 1+ pedal edema.
- D. 3+ protein on urine dipstick.
Correct Answer: D
Rationale: Significant proteinuria suggests worsening preeclampsia.
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After a dilatation and curettage(D&C) to evacuate a molar pregnancy, assessing the client for signs and symptoms of which of the following would be most important?
- A. Urinary tract infection.
- B. Hemorrhage.
- C. Abdominal distention.
- D. Chorioamnionitis.
Correct Answer: B
Rationale: Hemorrhage is a potential complication after D&C.
The nurse is catheterizing a client who cannot void after a normal delivery 8 hours ago. The nurse begins the catheterization process and the client asks the nurse if Betadine was used to clean the meatus for the catheterization. The nurse realizes that the client is allergic to Betadine and the client is reacting to the cleansing agent. The nurse should take the following steps in order of priority from first to last.
- A. Document incident.
- B. Clean Betadine from client's vaginal area.
- C. Notify physician ordering catheterization.
- D. Ask client what her reaction is when exposed to Betadine.
- E. File an incident report.
Correct Answer: B,D,C,A,E
Rationale: First, clean the Betadine to stop the reaction, ask about the reaction to assess severity, notify the physician, document the incident, and file an incident report.
A primiparous client asks when to transition her bottle-fed neonate to a sippy cup. The nurse should recommend introducing a sippy cup around:
- A. 3 months.
- B. 6 months.
- C. 9 months.
- D. 12 months.
Correct Answer: D
Rationale: Introducing a sippy cup around 12 months aligns with developmental readiness for independent drinking.
A multigravid client at 34 weeks' gestation is being treated with indomethacin(Indocin) to halt preterm labor. If the client delivers a preterm infant, the nurse should notify the nursery personnel about this therapy because of the possibility for which of the following?
- A. Pulmonary hypertension.
- B. Respiratory distress syndrome(RDS).
- C. Hyperbilirubinemia.
- D. Cardiomyopathy.
Correct Answer: C
Rationale: Indomethacin can increase the risk of hyperbilirubinemia in preterm infants.
The nurse is to assess a newborn for incurving of the trunk. Which illustration indicates the position in which the nurse should place the newborn?
Correct Answer: B
Rationale: To assess for incurving of the trunk, the newborn should be placed in a side-lying position to observe spinal curvature.