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The nurse is reviewing the adolescent's medical record. Which of the following conditions is the client most likely developing? Complete the following sentence by using the list of options. The adolescent is most likely developing -------------------------- evidenced by --------------------------
- A. Pelvic inflammatory disease
- B. Ectopic pregnancy
- C. C-reactive protein
- D. Beta hCG level
- E. Urinalysis
Correct Answer:
Rationale: Correct Answer: A: Pelvic inflammatory disease
Rationale: Pelvic inflammatory disease (PID) is a common condition in adolescents due to sexually transmitted infections. The nurse reviewing the medical record indicates a focus on the reproductive system. Ectopic pregnancy and Beta hCG levels are related but not the most likely in this case. C-reactive protein and urinalysis are general tests not specific to PID.
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complete the following sentence by using the lists of options. The client is at highest risk for developing ---evidenced by the client's ---
- A. Endometritis.
- B. Mastitis.
- C. Postpartum hemorrhage.
- D. Group B streptococcus positive status.
- E. Spontaneous vaginal delivery.
- F. Median episiotomy.
Correct Answer: A
Rationale: The correct answer is A: Endometritis. The client is at highest risk for developing endometritis evidenced by the client's median episiotomy. Endometritis is an infection of the lining of the uterus and is commonly associated with invasive procedures like episiotomy. The incision from a median episiotomy provides a pathway for bacteria to enter the uterus, increasing the risk of infection. The other choices are incorrect because mastitis is related to breastfeeding, postpartum hemorrhage is excessive bleeding after childbirth, group B streptococcus positive status is a risk for neonatal infection, and spontaneous vaginal delivery is a mode of delivery not directly related to endometritis.
Which of the following findings should the nurse report to the provider?Select the 3 findings that should be reported.
- A. Uterine contractions
- B. Fetal heart rate
- C. Gestational age
- D. Vaginal examination
- E. Maternal blood pressure
Correct Answer: A,B,D
Rationale: The nurse should report uterine contractions (A) to monitor for preterm labor, fetal heart rate (B) to assess fetal well-being, and vaginal examination (D) to evaluate cervical changes. Gestational age (C) is typically known and doesn't require immediate reporting. Maternal blood pressure (E) is important but not a priority in this context.
A nurse is assessing a client who is at 30 weeks of gestation during a routine prenatal visit. Which of the following findings should the nurse report to the provider?
- A. Swelling of the face
- B. Varicose veins in the calves
- C. Nonpitting 1+ ankle edema
- D. Hyperpigmentation of the cheeks
Correct Answer: A
Rationale: The correct answer is A: Swelling of the face. This finding can indicate preeclampsia, a serious pregnancy complication characterized by high blood pressure and protein in the urine. Preeclampsia poses risks to both the mother and the baby, so prompt reporting to the provider is crucial for timely intervention. Varicose veins in the calves (B) are common in pregnancy due to increased pressure on the veins but do not require immediate provider notification. Nonpitting 1+ ankle edema (C) is a common finding in pregnancy and is not typically concerning unless it worsens significantly. Hyperpigmentation of the cheeks (D) is a common benign finding known as melasma and does not require immediate reporting unless accompanied by other concerning symptoms.
A nurse is assessing a newborn who was born at 26 weeks of gestation using the New Ballard Score. Which of the following findings should the nurse expect?
- A. Minimal arm recoil
- B. Popliteal angle of 90°
- C. Creases over the entire foot sole
- D. Raised areolas with 3 to 4 mm buds
Correct Answer: A
Rationale: The correct answer is A: Minimal arm recoil. In premature newborns born at 26 weeks of gestation, they typically exhibit minimal arm recoil due to their immature neuromuscular development. This is a key characteristic assessed in the New Ballard Score to determine the gestational age of the newborn. Choices B, C, and D are incorrect as they do not align with the expected findings in a premature newborn at 26 weeks of gestation. Popliteal angle of 90° (Choice B) is more typical in a term newborn. Creases over the entire foot sole (Choice C) are also more common in term newborns. Raised areolas with 3 to 4 mm buds (Choice D) are indicative of a more mature newborn and not typically seen in a premature newborn at 26 weeks of gestation.
A nurse in a prenatal clinic is assessing a group of clients. Which of the following clients should the nurse see first?
- A. A client who is at 11 weeks of gestation and reports abdominal cramping.
- B. A client who is at 15 weeks of gestation and reports tingling and numbness in right hand.
- C. A client who is at 20 weeks of gestation and reports constipation for the past 4 days.
- D. A client who is at 8 weeks of gestation and reports having three bloody noses in the past week.
Correct Answer: A
Rationale: The correct answer is A: A client who is at 11 weeks of gestation and reports abdominal cramping. Abdominal cramping in early pregnancy could indicate a potential threat of miscarriage or ectopic pregnancy, which require immediate assessment to ensure the safety of the client and the pregnancy. Clients experiencing this symptom need prompt evaluation to rule out any serious complications. Choices B, C, and D do not pose immediate risks to the client or the pregnancy and can be addressed after ensuring the safety of the client in choice A. Numbness and tingling in the hand (choice B) may be due to carpal tunnel syndrome, while constipation (choice C) and bloody noses (choice D) are common pregnancy symptoms that can be managed through non-urgent interventions.