Nokea
A client at 39 weeks' gestation is in labor and reports intense back pain. What is the likely cause?
- A. Occiput posterior fetal position.
- B. Placental abruption.
- C. Breech presentation.
- D. Uterine rupture.
Correct Answer: A
Rationale: Intense back pain during labor is commonly associated with the occiput posterior fetal position.
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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.
What is the most appropriate action for a nurse when a newborn has jaundice on the second day of life?
- A. Increase fluid intake of the mother
- B. Phototherapy
- C. Monitor bilirubin levels
- D. Refer to a pediatric specialist
Correct Answer: B
Rationale: Phototherapy helps treat jaundice by breaking down bilirubin.
The nurse is educating a patient on what constitutes IPV. What is an example of an act of IPV?
- A. child endangerment
- B. stalking
- C. workplace harassment
- D. legal allegations
Correct Answer: B
Rationale: Stalking is a deliberate act where the perpetrator repeatedly follows, harasses, or intimidates the victim, which can instill fear or threaten safety. It is recognized as a specific form of intimate partner violence (IPV).
A nurse is conducting a discharge teaching for a client going home after cesarean section. Which S&S should the client be taught to report?
- A. Frequency urgency and burning on urination
- B. Feeling pelvic fullness
- C. Redness or edema of abdominal decision
- D. Mild incisional pain
Correct Answer: A
Rationale: After a cesarean section, the client should be taught to report symptoms of a urinary tract infection, such as frequency, urgency, and burning on urination. These symptoms can indicate an infection which needs prompt treatment to prevent complications. It is important for the client to report these symptoms to their healthcare provider for appropriate evaluation and management.
A nurse is admitting a client who is at 33 weeks of gestation and has preeclampsia with severe features. Which of the following actions should the nurse take?
- A. Restrict protein intake to less than 40 g/day.
- B. Initiate seizure precautions for the client.
- C. Initiate an infusion of 0.9% sodium chloride at 150 mL/hr.
- D. Encourage the client to ambulate twice per day.
Correct Answer: B
Rationale: In a client with preeclampsia with severe features at 33 weeks of gestation, initiating seizure precautions is a priority nursing action. Preeclampsia with severe features places the client at an increased risk for seizures. Therefore, the nurse should ensure that seizure precautions are in place, such as maintaining a safe environment, pad the side rails of the bed, and have emergency medications and equipment readily available. Monitoring for signs and symptoms of worsening preeclampsia and impending seizures is crucial for the client's safety and well-being.