Nokea
A 17-year-old pregnant client who is gravida 1, para 0, is at 36 weeks' gestation. Based on the nurse's knowledge of the maternal physiological changes in pregnancy, which of these findings would be of concern?
- A. Complaints of dyspnea
- B. Edema of face and hands
- C. Pulse of 65 bpm at 8 weeks, 73 bpm at 36 weeks
- D. Hematocrit 39%
Correct Answer: B
Rationale: Edema of the face, hands, or pitting edema after 12 hours of bed rest may be indicative of preeclampsia and would be of great concern to the healthcare provider.
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The nurse is caring for a client with a diagnosis of postpartum endometritis. Which intervention is most appropriate?
- A. Administer antibiotics
- B. Monitor fetal heart tones
- C. Prepare for cesarean delivery
- D. Administer tocolytics
Correct Answer: A
Rationale: Postpartumndometritis require es antibiotics to treat the uterine infection. Fetal heart tones are irrelevant postpartum cesarean delivery is not indicated and tocolytics are for preterm labor.
The nurse is teaching a client with a history of chronic kidney disease about dietary modifications. The nurse should tell the client to:
- A. Limit phosphorus intake
- B. Increase sodium intake
- C. Consume high-potassium foods
- D. Increase protein intake
Correct Answer: A
Rationale: Limiting phosphorus intake prevents bone and cardiovascular complications in chronic kidney disease.
To facilitate maximum air exchange, the nurse should position the client in:
- A. High Fowler
- B. Orthopneic
- C. Prone
- D. Flat-supine
Correct Answer: B
Rationale: The orthopneic position is a sitting position that allows maximum lung expansion.
A diagnosis of hepatitis C is confirmed by a male client's physician. The nurse should be knowledgeable of the differences between hepatitis A, B, and C. Which of the following are characteristics of hepatitis C?
- A. The potential for chronic liver disease is minimal.
- B. The onset of symptoms is abrupt.
- C. The incubation period is 2-26 weeks.
- D. There is an effective vaccine for hepatitis B, but not for hepatitis C.
Correct Answer: C
Rationale: Hepatitis C has an incubation period of 2-26 weeks. It has a high potential for chronic liver disease, an insidious onset, and no effective vaccine, unlike hepatitis B.
The following are all nursing diagnoses appropriate for a gravida 1 para 0 in labor. Which one would be most appropriate for the primigravida as she completes the early phase of labor?
- A. Impaired gas exchange related to hyperventilation
- B. Alteration in placental perfusion related to maternal position
- C. Impaired physical mobility related to fetal-monitoring equipment
- D. Potential fluid volume deficit related to decreased fluid intake
Correct Answer: D
Rationale: In early labor primigravidas may have reduced fluid intake due to nausea or restrictions increasing the risk of fluid volume deficit. This is more common than impaired gas exchange placental perfusion issues or mobility limitations at this stage.