Nokea
A client is admitted to the labor and delivery unit in active labor. The physician performs an amniotomy. Which observation would the nurse expect to make immediately after the amniotomy?
- A. Fetal heart tones 160 bpm
- B. Moderate uterine contractions
- C. A large amount of straw-colored fluid
- D. Thick green amniotic fluid
Correct Answer: C
Rationale: After an amniotomy the nurse expects to observe a large amount of clear or straw-colored amniotic fluid indicating normal amniotic fluid. Fetal heart tones of 160 bpm are normal but not specific to amniotomy contractions are unrelated and green fluid suggests meconium which is abnormal.
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A type I diabetic client is diagnosed with cellulitis in his right lower extremity. The nurse would expect which of the following to be present in relation to his blood sugar level?
- A. A normal blood sugar level
- B. A decreased blood sugar level
- C. An increased blood sugar level
- D. Fluctuating levels with a predawn increase
Correct Answer: C
Rationale: Hyperglycemia occurs due to glucose production in response to the stress and illness of cellulitis.
Which statement by the parent of a child with sickle cell anemia indicates an understanding of the disease?
- A. The pain he has is due to the presence of too many red blood cells.
- B. He will be able to go snow skiing with his friends as long as he stays warm.
- C. He will need extra fluids in summer to prevent dehydration.
- D. There is very little chance that his brother will have sickle cell.
Correct Answer: C
Rationale: Sickle cell anemia increases dehydration risk due to impaired blood flow, especially in heat. Extra fluids in summer prevent crises. Pain is due to vaso-occlusion, not excess RBCs, and skiing poses risks.
The nurse is removing a peripherally inserted central catheter (PICC). The nurse should position the patient in which position?
- A. Fowlers
- B. Right side lying
- C. Left side lying
- D. Trendelenburg
Correct Answer: D
Rationale: Trendelenburg position (head down) is used when removing a PICC line to reduce the risk of air embolism by increasing venous pressure. Fowler’s, right, or left side-lying positions do not provide this protection.
The client is admitted with a diagnosis of abruptio placenta. Which complication is most likely to occur?
- A. Fetal distress
- B. Maternal hemorrhage
- C. Both A and B
- D. Neither A nor B
Correct Answer: C
Rationale: Abruptio placenta causes placental separation leading to fetal distress (from hypoxia) and maternal hemorrhage (from bleeding). Both are common and serious complications.
A 25-year-old lawyer who is married with three young children works long hours in an effort to become a partner in the law firm. Following a recent hospitalization for a bleeding ulcer, he was referred for therapy to treat this psychophysiological disorder. On meeting with the therapist, he informed him or her that he was a busy man and did not have much time for this 'psych stuff.' When guiding the client to ventilate his feelings, the therapist can expect him to express feelings of:
- A. Guilt
- B. Shame
- C. Despair
- D. Anger
Correct Answer: D
Rationale: Repressed anger is associated with psychophysiological disorders like a bleeding ulcer, as stress and unexpressed emotions contribute to physical symptoms.