Nokea
A client in active labor is admitted with preeclampsia. Which assessment finding is most significant in planning this client's care?
- A. Patellar reflex 4+
- B. Blood pressure 158/80
- C. Four-hour urine output 240 ml
- D. Respirations 12/minute
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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A male infant with a 2-day history of fever and diarrhea is brought to the clinic by his mother, who tells the nurse that the child refuses to drink anything. The nurse determines that the child has a weak cry with no tears. Which intervention is most important to implement?
- A. Provide a bottle of electrolyte solution.
- B. Infuse normal saline intravenously.
- C. Administer an antipyretic rectally.
- D. Apply an external cooling blanket.
Correct Answer: B
Rationale: Infusing normal saline intravenously is crucial to treat dehydration caused by fever and diarrhea. In this scenario, the infant's weak cry with no tears indicates severe dehydration, necessitating rapid fluid replacement via intravenous normal saline to restore fluid balance and prevent complications.
What should the nurse recommend to a woman with mastitis?
- A. Apply heat to the affected area.
- B. Apply cold compresses to the affected area.
- C. Use a breast pump to express milk.
- D. Continue breastfeeding as usual.
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The healthcare provider is reviewing the serum laboratory findings for a 5-day-old infant with congenital adrenal hyperplasia. Which laboratory result should be reported to the healthcare provider immediately?
- A. Bilirubin of 1.5 mg/dl.
- B. Glucose of 80 mg/dl.
- C. Potassium of 4.5 mEq/L.
- D. Sodium of 119 mEq/L.
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
In which chromosome pattern is Duchenne disease inherited?
- A. Autosomal dominant
- B. Autosomal recessive
- C. X-linked recessive
- D. Mitochondrial
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
While caring for a laboring client on continuous fetal monitoring, the nurse notes a fetal heart rate pattern that falls and rises abruptly with a 'V' shaped appearance. What action should the nurse take first?
- A. Change the maternal position.
- B. Administer oxygen at 10 L by mask.
- C. Prepare for a potential cesarean.
- D. Allow the client to begin pushing.
Correct Answer: A
Rationale: In cases of fetal heart rate patterns showing abrupt falls and rises with a 'V' shaped appearance, it indicates possible cord compression. Changing the maternal position, such as moving the mother onto her side, can relieve the pressure off the cord and help improve fetal oxygenation, making it the priority intervention to address the decelerations.