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A 34-year-old client who is gravida 1, para 0 has a history of infertility and conceived this pregnancy while taking fertility drugs. She is at 32 weeks' gestation and is carrying triplets. She is complaining of low back pain and a feeling of pelvic pressure. Her cervical exam reveals a long, closed cervix. The nurse notes that the client is experiencing mild uterine contractions every 7-8 minutes after the nurse has placed her on the fetal monitor. Her condition should indicate that:
- A. Her cervix shows she will likely deliver soon
- B. The nurse should not be alarmed because mild uterine activity is common at 32 weeks' gestation
- C. She may be in preterm labor because this is more common with multiple pregnancies
- D. She most likely has a urinary tract infection (UTI) because this is common with pregnancy
Correct Answer: C
Rationale: Rhythmical contractions in conjunction with low back pain and pelvic pressure at 32 weeks in a woman carrying triplets are of great concern, indicating possible preterm labor, which is more common in multiple pregnancies.
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The nurse is caring for a client hospitalized with bipolar disorder, manic phase. Which of the following snacks would be best for the client?
- A. Potato chips
- B. Diet cola
- C. Apple
- D. Milkshake
Correct Answer: C
Rationale: An apple is a healthy, easy-to-eat snack that provides nutrition without excessive sodium (chips), caffeine (cola), or high calories (milkshake), suitable for a manic client needing stability.
Home-care instructions for the child following a cardiac catheterization should include:
- A. Notify the physician if a slight bruise develops around the insertion site.
- B. Use sponge bathing until stitches are removed.
- C. Give aspirin if the child complains of pain at the insertion site.
- D. Keep a clean, dry dressing on the insertion site for 2 days.
Correct Answer: B
Rationale: A small bruise may develop around the insertion site and is not a reason for alarm. It is best to keep the child out of the bathtub until the sutures are removed. Acetaminophen, not aspirin, is the drug of choice if there is pain at the insertion site. The insertion site should be kept clean and dry and open to air.
The nurse notes hyperventilation in a client with a thermal injury. She recognizes that this may be a reaction to which of the following medications if applied in large amounts?
- A. Neosporin sulfate
- B. Mafenide acetate
- C. Silver sulfadiazine
- D. Povidone-iodine
Correct Answer: B
Rationale: Mafenide acetate can cause metabolic acidosis, leading to compensatory hyperventilation. The other medications listed do not typically cause this reaction.
A client with a history of a ventricular tachycardia is receiving Amiodarone (Cordarone). The nurse should monitor the client for:
- A. Hypotension
- B. Hyperglycemia
- C. Hypokalemia
- D. Pulmonary toxicity
Correct Answer: D
Rationale: Amiodarone can cause pulmonary toxicity, a serious side effect requiring monitoring for cough or dyspnea. Hypotension is possible but less specific, and hyperglycemia/hypokalemia are unrelated.
Diabetes during pregnancy requires tight metabolic control of glucose levels to prevent perinatal mortality. When evaluating the pregnant client, the nurse knows the recommended serum glucose range during pregnancy is:
- A. 70 mg/dL and 120 mg/dL
- B. 100 mg/dL and 200 mg/dL
- C. 40 mg/dL and 130 mg/dL
- D. 90 mg/dL and 200 mg/dL
Correct Answer: A
Rationale: The recommended range is 70-120 mg/dL to reduce the risk of perinatal mortality. (B, C, D) These levels are not recommended. The higher the blood glucose, the worse the prognosis for the fetus. Hypoglycemia can also have detrimental effects on the fetus.