Nokea
A 23-year-old woman at 32-weeks gestation is seen in the outpatient clinic.
- A. Which finding indicates a possible complication in a 23-year-old woman at 32-weeks gestation?
- B. The client’s urine Test is positive for glucose and acetone.
- C. The client has 1+ pedal edema in both feet at the end of the day.
- D. The client complains of an increase in vaginal discharge.
- E. The client says she feels pressure against her diaphragm when the baby moves.
Correct Answer: A
Rationale: Glucose and acetone in urine suggest possible gestational diabetes, which can lead to placental insufficiency and fetal complications, requiring immediate evaluation. Mild edema, increased vaginal discharge, and diaphragmatic pressure are common in late pregnancy and not necessarily indicative of complications.
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While a two-day-old infant is in surgery for repair of spina bifida, the infant's mother expresses concern to the nurse because the doctor told her the infant would be confined to a wheelchair. Which of the following statements, if made by the nurse, is BEST?
- A. Physical therapy can restore the function to affected muscles.
- B. Orthopedic devices will allow your child to strengthen lower extremity muscles.
- C. Corrective surgery will return function to the affected muscles.
- D. The corrective surgery will not change your child's physical disability.
Correct Answer: D
Rationale: spinal nerves that are destroyed by the myelomeningocele cannot be corrected; nothing can return function to portions of the body that are innervated by the spinal nerves below the site of the myelomeningocele
A client is scheduled for an intravenous pyelogram (IVP).
Nursing management prior to an intravenous pyelogram (IVP) would include which of the following?
- A. A fat-free meal the evening prior to the examination and radiopaque tablets at bedtime.
- B. Placement of a retention urinary catheter to facilitate dilation of the bladder sphincter.
- C. Cleansing enemas the evening before to provide for adequate visualization of the urinary tract.
- D. Explaining the importance of following directions regarding voiding during the Test .
Correct Answer: C
Rationale: Strategy: Answers are all implementations. Determine the outcome of each answer choice. Is it desired? (1) fat-free meal is associated with a gall bladder series (2) a retention Foley catheter may be in place, but not for the purpose of dilating the bladder sphincter (3) correct-because of the need to visualize the abdominal area, cleansing enemas the evening before an IVP are usually ordered (4) there are few directions the client needs to follow during the Test
A client who is a gravida 2, para 1 has been admitted for induction of labor with oxytocin (Pitocin).
It would be MOST important for the nurse to take which of the following actions?
- A. Mix Pitocin in D5W, begin at 5 mg/cc as primary IV to gravity flow.
- B. Decrease the rate/flow of Pitocin if the fetal heart rate is below 150.
- C. Piggyback the Pitocin into the mainline IV and maintain the flow by gravity.
- D. Start an IV line and piggyback the Pitocin with an infusion pump.
Correct Answer: D
Rationale: Strategy: The topic of the question is unstated. Read the answer choices for clues. (1) Pitocin should be a secondary infusion (2) normal range for fetal heart tones is 120 to 160 beats per minute (3) rate should be maintained by an infusion pump (4) correct-Pitocin should always be a secondary infusion controlled by an IV pump
A client with a statement indicating the use of a defense mechanism.
Which of the following statements, if made by a client to the nurse, would indicate that the client is using the defense mechanism of conversion?
- A. I love my family with all my heart even though they don't love me.'
- B. I was unable to take my final exams because I was unable to write.'
- C. I don't believe I have diabetes. I feel perfectly fine.'
- D. If my wife was a better housekeeper I wouldn't have such a problem.'
Correct Answer: B
Rationale: Strategy: Think about each answer choice. (1) indicates reaction formation (2) correct-client has converted his anxiety over school performance into a physical symptom that interferes with his ability to perform (3) indicates denial (4) indicates projection
The nurse is performing an ice massage for a client in chronic pain. The nurse is MOST concerned if which of the following is observed?
- A. Redness or inflammation of the tissue.
- B. Mottling or graying of the tissue.
- C. The client states that she feels a burning and tingling sensation in the area.
- D. The client states that she feels a numbness and a cold sensation in the area.
Correct Answer: B
Rationale: Mottling or graying indicates potential frostbite or tissue damage, a serious concern requiring immediate cessation of ice massage. Options A, C, and D are less critical: redness is common, burning/tingling suggests ischemia, and numbness/cold is expected.