Nokea
A client in labor admits to using alcohol throughout the pregnancy. The most recent use was the day before. Based on the client's history, the nurse should give priority to assessing the newborn for:
- A. Respiratory depression
- B. Wide-set eyes
- C. Jitteriness
- D. Low-set ears
Correct Answer: C
Rationale: Fetal alcohol exposure, especially recent use, can cause neonatal withdrawal symptoms like jitteriness. Respiratory depression is less common, and physical anomalies like wide-set eyes or low-set ears are associated with chronic exposure.
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The client is admitted to the unit with a diagnosis of abruptio placenta. Which finding is most significant when assessing this client?
- A. Bright red vaginal bleeding
- B. Abdominal pain and rigidity
- C. Alteration in the fetal heart tones
- D. A soft,boggy uterus
Correct Answer: C
Rationale: Abruptio placenta involves placental separation which can compromise fetal oxygenation leading to abnormal fetal heart tones (e.g. bradycardia or late decelerations). This is the most significant finding as it indicates fetal distress. Bleeding pain and rigidity are relevant but secondary to fetal well-being.
Which client clinical manifestation during a bone marrow transplantation procedure alerts the nurse to the possibility of an adverse reaction?
- A. Fever
- B. Red colored urine
- C. Hypertension
- D. Shortness of breath
Correct Answer: D
Rationale: Shortness of breath may indicate an acute transfusion reaction (e.g., TRALI) during bone marrow transplantation, requiring immediate action. Fever (A), red urine (B), and hypertension (C) are less specific or expected.
The nurse is caring for a client with a diagnosis of preterm labor. Which medication is most likely to be ordered?
- A. Betamethasone
- B. Terbutaline
- C. Magnesium sulfate
- D. All of the above
Correct Answer: D
Rationale: Betamethasone promotes fetal lung maturity terbutaline and magnesium sulfate are tocolytics to halt preterm contractions and magnesium may also provide neuroprotection. All are commonly ordered in preterm labor.
Which of the following diagnoses require droplet precautions?
- A. Varicella
- B. Rubella
- C. Streptococcal pharyngitis
- D. Scarlet fever
- E. Shigella
- F. Hepatitis A
Correct Answer: B, C, D
Rationale: Rubella (B), streptococcal pharyngitis (C), and scarlet fever (D) are transmitted via respiratory droplets, requiring droplet precautions. Varicella (A) requires airborne precautions, while Shigella (E) and hepatitis A (F) are transmitted fecally-orally, requiring contact precautions.
The nurse is caring for a client with a history of a fractured femur who is in a cast. The client complains of swelling. The nurse should:
- A. Apply ice to the cast
- B. Elevate the leg
- C. Massage the leg
- D. Notify the physician immediately
Correct Answer: B
Rationale: Elevating the leg reduces swelling in a casted femur by improving venous return. Ice is helpful, massage is contraindicated, and notification is needed if swelling persists.