Nokea
A 30 years old G3P2 at 28 weeks of gestation presents with severe pain in the right flank radiating to her groin. She also complaints of rigors and chills. Urine analysis reveals numerous pus cells. The most likely diagnosis is:
- A. Appendicitis.
- B. Pyelonephritis.
- C. Round ligament torsion.
- D. Meckel's diverticulum.
- E. Torsion of ovarian cyst.
Correct Answer: B
Rationale: Pyelonephritis a urinary tract infection affecting the kidneys presents with flank pain fever,chills,and pus cells in urine,as described. Appendicitis typically involves right lower quadrant pain and other options lack urinary findings or are less likely in pregnancy.
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During preoperative preparation, which nursing action is most appropriate?
- A. Give analgesics.
- B. Give nothing by mouth (NPO).
- C. Give an enema.
- D. Apply heat to the abdomen.
Correct Answer: B
Rationale: Keeping the patient NPO prevents aspiration during surgery and reduces complications, as food in the stomach could interfere with anesthesia.
Pregnancy induced hypertension is diagnosed when:
- A. Hypertension is encountered after 20 weeks of gestation.
- B. Hypertension gets worse in first week of pregnancy.
- C. Hypertension is not controlled with aldomet.
- D. Hypertension gives rise to left ventricular failure.
- E. Blood urea & creatine levels in blood are abnormal.
Correct Answer: A
Rationale: Pregnancy-induced hypertension (gestational hypertension) is diagnosed when hypertension (BP ≥140/90 mmHg) appears after 20 weeks gestation without proteinuria or other preeclampsia features.
The nurse is caring for the infant in the neonatal ICU who has an umbilical artery catheter (UAC) in place. To monitor for and prevent complications with this catheter,which actions should be planned by the nurse? Select all that apply.
- A. Check the position marking on the catheter every shift.
- B. Position the tubing close to the infant’s lower limbs.
- C. Check for erythema or discoloration of the abdominal wall.
- D. Palpate for femoral,pedal,and tibial pulses every 2 to 4 hours.
- E. Reposition the catheter tubing every hour.
- F. Monitor blood glucose levels.
Correct Answer: A,C,D,F
Rationale: Check catheter position abdominal wall pulses every 2–4 hours and glucose levels to monitor for displacement bleeding perfusion issues or hypoglycemia. Keep tubing away from limbs and avoid frequent repositioning to reduce infection risk.
The nurse receives a laboratory report result showing that the blood glucose is 48 mg/dL for a full-term newborn. Which action should be taken by the nurse?
- A. Have the mother breastfeed her newborn now.
- B. Immediately feed the infant water with 10% dextrose.
- C. Report the results immediately to the health care provider.
- D. Document the information in the newborn’s medical record.
Correct Answer: D
Rationale: Normal blood sugar values for a full-term newborn are 45–65 mg/dL. A value of 48 mg/dL is normal so the only action required is documentation. Feeding or reporting is unnecessary.
Which question is most important for the nurse to ask the adolescent girl in preparation for X-rays?
- A. Is there any possibility that you're pregnant?
- B. Have you eaten anything in the past 24 hours?
- C. Have you taken any medications in the past 24 hours?
- D. Are you allergic to iodine or shellfish?
Correct Answer: A
Rationale: Asking about pregnancy is critical before X-rays, as radiation can harm a fetus, making it the most important question to ensure safety.