Nokea
A 60-year-old client with a palpable mass to the right adnexa and family history of ovarian cancer is seen by the HCP. The nurse anticipates the order for which of the following laboratory results?
- A. CBC
- B. Blood glucose
- C. CA-125
- D. FSH and LH
Correct Answer: C
Rationale: The correct answer is C: CA-125. This tumor marker is used to assess for ovarian cancer in high-risk individuals. The client's age, palpable mass, and family history of ovarian cancer raise suspicion for malignancy. A CBC (choice A) and blood glucose (choice B) are not specific to ovarian cancer evaluation. FSH and LH (choice D) are hormone levels that do not directly assess for ovarian cancer. Therefore, CA-125 is the most appropriate lab test to anticipate in this scenario.
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Intrapartum nursing care for a woman who has sickle cell disease focuses on:
- A. Maintaining oxygenation and preventing dehydration
- B. Controlling pain and avoiding unnecessary movement
- C. Preventing excess exertion and limiting visitors
- D. Increasing calorie intake and avoiding internal monitoring
Correct Answer: A
Rationale: The correct answer is A because maintaining oxygenation is crucial due to the risk of vaso-occlusive crisis in sickle cell disease. Dehydration can worsen sickling of red blood cells. Choice B is incorrect because pain control is important but not the primary focus. Choice C is incorrect as excess exertion can trigger a crisis, and limiting visitors is not a priority. Choice D is incorrect as calorie intake and internal monitoring are not directly related to intrapartum care for sickle cell disease.
The correct injection technique for infants of mothers who are known carriers of hepatitis B virus is to:
- A. Avoid all intramuscular injections until 1 month of age
- B. Dilute intramuscular injections with added normal saline
- C. Mix all injections that the infant will need in a single syringe
- D. Bathe the area where the infant will receive injections
Correct Answer: A
Rationale: The correct answer is A because infants born to mothers who are known carriers of hepatitis B virus should receive the hepatitis B vaccine within 12 hours of birth. Delaying intramuscular injections until 1 month of age increases the risk of vertical transmission of the virus. Choice B is incorrect because diluting injections with normal saline is unnecessary and may compromise the effectiveness of the vaccine. Choice C is incorrect as mixing all injections in a single syringe can lead to contamination and inaccurate dosing. Choice D is incorrect as bathing the injection site does not prevent vertical transmission of the virus.
For HIV treatment, the pregnant woman should be expected to receive:
- A. Antibiotics
- B. Protease analogues
- C. Zidovudine
- D. Acyclovir
Correct Answer: C
Rationale: Rationale:
1. Zidovudine (AZT) is recommended for HIV-infected pregnant women to reduce the risk of vertical transmission to the baby.
2. It inhibits viral replication and decreases viral load in the mother, reducing transmission to the fetus.
3. Antibiotics are not effective for HIV treatment. Protease analogues are not typically used in pregnancy due to safety concerns. Acyclovir is used for herpes simplex virus, not HIV.
A 58-year-old woman tells the nurse that she has started to experience pain during intercourse. The nurse should document that this woman is experiencing which of the following?
- A. Dyspnea
- B. Dyspareunia
- C. Dyspepsia
- D. Dysmenorrhea
Correct Answer: B
Rationale: The correct answer is B: Dyspareunia. Dyspareunia refers to pain during or after sexual intercourse. In this case, the woman is experiencing pain during intercourse, which aligns with the definition of dyspareunia. Dyspnea (A) is difficulty breathing, dyspepsia (C) is indigestion, and dysmenorrhea (D) is painful menstruation, none of which are related to pain during intercourse.
The nurse is grading a woman's reflexes. Which of the following grades would indicate reflexes that are slightly brisker than normal?
- A. +1.'
- B. +2.'
- C. +3.'
- D. +4.'
Correct Answer: C
Rationale: The correct answer is C: +3'. This indicates brisk reflexes. A: +1' indicates a low-normal response, B: +2' indicates a normal response, and D: +4' indicates hyperactive reflexes. +3' is slightly brisker than normal, reflecting an increased response without being hyperactive.