Nokea
A client at 28 weeks' gestation reports feeling fewer fetal movements. What should the nurse recommend first?
- A. Perform a nonstress test.
- B. Drink a glass of juice and lie down.
- C. Notify the healthcare provider immediately.
- D. Schedule an ultrasound.
Correct Answer: B
Rationale: Drinking juice and lying down can stimulate fetal movement and help evaluate whether further action is needed.
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The nurse assess that a newborn is in respiratory distress when the infant exhibits:
- A. Apnea, grunting, wheezing, and crackles
- B. Wheezing, cyanosis, hiccups, and crackles
- C. Cyanosis, retraction, wheezing, and hiccups
- D. Tachypnea, retraction, grunting, and cyanosis
Correct Answer: D
Rationale: In newborns, respiratory distress can present with various signs and symptoms. The combination of tachypnea (rapid breathing), chest retractions (visible sinking of the skin in between or below the ribs with each breath), grunting (sound made during expiration), and cyanosis (blue discoloration of the skin and mucous membranes) are indicative of respiratory distress in a newborn. These signs suggest that the newborn is having difficulty breathing and may require immediate medical attention. It is essential to recognize and address respiratory distress promptly to ensure the well-being of the newborn.
The nurse is attempting to explain physiologic birth. What do they say?
- A. Physiologic birth involves interventions that do not harm the baby.â€
- B. Physiologic birth occurs only in birth centers.â€
- C. If your partner and I give you support, you can have a birth without medical intervention.â€
- D. If you want to have a cesarean birth, we can ask your health-care provider to schedule it.â€
Correct Answer: C
Rationale: Physiologic birth focuses on minimal intervention, supported by a calm environment and supportive care.
The nurse is monitoring a client with premature rupture of membranes at 37 weeks. Which prescription should the nurse question?
- A. Monitor fetal heart rate continuously.
- B. Monitor maternal vital signs frequently.
- C. Perform a vaginal examination every shift.
- D. Administer an antibiotic as prescribed.
Correct Answer: C
Rationale: Vaginal exams are minimized to reduce the risk of infection in clients with premature rupture of membranes.
A client with acute respiratory failure (ARF) may present with which of the following manifestations? (Select one that doesn't apply.)
- A. Severe dyspnea
- B. Decreased level of consciousness
- C. Headache
- D. Nausea
Correct Answer: D
Rationale: In acute respiratory failure (ARF), the body is not getting enough oxygen, leading to respiratory distress. Symptoms of ARF typically include severe dyspnea (difficulty breathing), decreased level of consciousness due to hypoxia, and headache from inadequate oxygenation to the brain. Nausea is not a typical manifestation of ARF and would not be expected in this condition.
A client with chronic kidney disease has arterial blood gas values being reviewed by a nurse. Which of the following sets of values should the nurse expect?
- A. pH 7.25, HCO3- 19 mEq/L, PaCO2 30 mm Hg
- B. pH 7.30, HCO3- 26 mEq/L, PaCO2 50 mm Hg
- C. pH 7.50, HCO3- 20 mEq/L, PaCO2 32 mm Hg
- D. pH 7.55, HCO3- 30 mEq/L, PaCO2 31 mm Hg
Correct Answer: A
Rationale: In chronic kidney disease, metabolic acidosis is common due to impaired kidney function leading to reduced bicarbonate excretion. The correct values indicating metabolic acidosis in this scenario are a low pH (acidosis), low bicarbonate (HCO3-) level, and low PaCO2 (compensation through respiratory alkalosis). Therefore, the expected values for a client with chronic kidney disease would be pH 7.25, HCO3- 19 mEq/L, PaCO2 30 mm Hg, as depicted in choice A.