Nokea
A client in sickle cell crisis has been hospitalized during her pregnancy. After giving discharge instructions, the nurse determines the client needs further teaching when she states which of the following?
- A. "I will need more frequent appointments during the remainder of the pregnancy."
- B. "Signs of any type of infection must be reported immediately."
- C. "At the earliest signs of a crisis, I need to seek treatment."
- D. "I have this disease because I don't eat enough food with iron."
Correct Answer: D
Rationale: Sickle cell disease is genetic, not caused by dietary iron deficiency.
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A nurse is teaching a client about the use of male condoms. Which of the following instructions should the nurse include?
- A. Use a water-based lubricant with latex condoms.
- B. Store condoms in a hot environment to maintain flexibility.
- C. Apply the condom after ejaculation for best results.
- D. Reuse condoms if they are undamaged.
Correct Answer: A
Rationale: Using a water-based lubricant with latex condoms prevents breakage and enhances comfort. Condoms should be stored in a cool, dry place, applied before any genital contact, and never reused.
A primiparous client has just delivered her baby. The physician has informed the labor nurse that he believes the uterus has inverted. Which of the following would help to confirm this diagnosis? Select all that apply.
- A. Hypotension.
- B. Gush of blood from the vagina.
- C. Intense, severe, tearing type of abdominal pain.
- D. Uterus is hard and in a constant state of contraction.
- E. Inability to palpate the uterus.
- F. Diaphoresis.
Correct Answer: A,E
Rationale: Uterine inversion is characterized by the uterus turning inside out, often leading to hypotension (due to shock) and inability to palpate the fundus abdominally. A gush of blood may occur but is not specific, severe pain is less common, the uterus is not typically hard, and diaphoresis is a secondary symptom.
A primigravid client admitted to the labor area in the upper and lower lower than the lower was born with cystic fibrosis and she wonders if her baby will also have the disease. The nurse can tell the client that cystic fibrosis is:
- A. X-linked recessive and the disease will only occur if the baby is a boy.
- B. X-linked dominant and there is no likelihood of the baby having cystic fibrosis.
- C. Autosomal recessive and that unless the baby's father has the gene, the baby will not have the disease.
- D. Autosomal dominant and there is a 50 per cent chance of the baby having the disease.
Correct Answer: C
Rationale: Cystic fibrosis is an autosomal recessive disorder, requiring both parents to carry the gene for the child to be affected. If the father does not carry the gene, the baby cannot have the disease but may be a carrier. X-linked and dominant inheritance patterns do not apply.
A primigravid client in active labor has had no anesthesia. The client's cervix is 7 cm dilated, and she is starting to feel considerable discomfort during the first 10 cm to the client's sacral client is a left side-lying position. The nurse should encourage which of the following?
- A. Rapid, shallow chest breathing.
- B. Deep chest breathing.
- C. Rapid pant-blow breathing.
- D. Slow abdominal breathing.
Correct Answer: D
Rationale: Slow abdominal breathing promotes relaxation and oxygenation, helping manage discomfort in active labor without anesthesia. Rapid or shallow breathing may lead to hyperventilation, and deep chest breathing is less effective for pain control.
A client at 15 weeks' gestation is admitted with dark brown vaginal bleeding and continuous nausea and vomiting. Her blood pressure is 142/98 and fundal height is 19 cm. The nurse should prepare to do which of the following?
- A. Transfer the client to the antenatal unit.
- B. Keep the client NPO for 24 hours.
- C. Administer magnesium sulfate.
- D. Obtain an ultrasound.
Correct Answer: D
Rationale: Ultrasound confirms the diagnosis of a hydatidiform mole.