Nokea
A client is preparing to administer methylergonovine 0.2 mg orally to a client who is 2 hr postpartum and has a boggy uterus. For which of the following assessment findings should the nurse withhold the medication?
- A. Blood pressure 142/92 mm Hg
- B. Urine output 100 mL in 1 hr
- C. Pulse 58/min
- D. Respiratory rate 14/min
Correct Answer: A
Rationale: The correct answer is A. Methylergonovine can increase blood pressure, so it should be withheld if the client has hypertension. A blood pressure reading of 142/92 mm Hg indicates hypertension and is a contraindication for administering methylergonovine. Choices B, C, and D are within normal limits and not contraindications for administering this medication. Urine output, pulse rate, and respiratory rate are not factors that determine the appropriateness of administering methylergonovine in this situation.
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A premature infant with respiratory distress syndrome (RDS) receives artificial surfactant. How does the nurse explain surfactant therapy to the parents?
- A. "Surfactant improves the ability of your baby's lungs to exchange oxygen and carbon dioxide."
- B. "The drug keeps your baby from requiring too much sedation."
- C. "Surfactant is used to reduce episodes of periodic apnea."
- D. "Your baby needs this medication to fight a possible respiratory tract infection."
Correct Answer: A
Rationale: Artificial surfactant can be administered as an adjunct to oxygen and ventilation therapy for premature infants with respiratory distress syndrome (RDS). It helps improve respiratory compliance by aiding in the exchange of oxygen and carbon dioxide until the infant can produce enough surfactant naturally. The correct explanation to the parents would be that surfactant therapy enhances the baby's lung function by facilitating the exchange of oxygen and carbon dioxide. Choice B is incorrect because surfactant therapy does not affect sedation needs. Choice C is inaccurate as surfactant is not used to reduce episodes of periodic apnea. Choice D is incorrect as surfactant is not administered to fight respiratory tract infections; it specifically targets improving lung function in RDS.
A client who is pregnant and follows a vegan diet asks a nurse for guidance on foods high in calcium. Which of the following foods has the highest amount of calcium?
- A. ½ cup cubed avocado
- B. 1 large banana
- C. 1 medium potato
- D. 1 cup cooked broccoli
Correct Answer: D
Rationale: The correct answer is D: 1 cup of cooked broccoli. Broccoli is an excellent source of calcium, making it a suitable choice for a vegan diet. Avocado (Choice A), banana (Choice B), and potato (Choice C) are not significant sources of calcium compared to broccoli. Avocado and banana are primarily sources of other nutrients like healthy fats and potassium, respectively. Potato is a good source of vitamin C and potassium but not calcium. Therefore, for a pregnant client following a vegan diet and seeking calcium-rich foods, cooked broccoli is the most appropriate choice.
What information should the nurse include when teaching a client at 41 weeks of gestation about a non-stress test?
- A. This test will confirm fetal lung maturity.
- B. This test will determine the adequacy of placental perfusion.
- C. This test will detect fetal infection.
- D. This test will predict maternal readiness for labor.
Correct Answer: B
Rationale: The correct answer is B: 'This test will determine the adequacy of placental perfusion.' The non-stress test is used to assess fetal well-being by monitoring the fetal heart rate in response to its own movements. It helps determine if the fetus is receiving enough oxygen and nutrients through placental perfusion. Choice A is incorrect because confirming fetal lung maturity is typically determined through tests like amniocentesis, not the non-stress test. Choice C is incorrect because detecting fetal infection is not the primary purpose of a non-stress test. Choice D is incorrect because predicting maternal readiness for labor is not the purpose of the non-stress test; it focuses on fetal well-being.
What causes sickle-cell anemia?
- A. A chromosomal abnormality.
- B. A single segment found only on the Y chromosome.
- C. A recessive gene.
- D. A decrease in estrogen levels.
Correct Answer: C
Rationale: Sickle-cell anemia is a genetic disorder caused by inheriting two copies of a recessive gene, one from each parent. The correct answer is C. Choice A is incorrect because sickle-cell anemia is not primarily caused by a chromosomal abnormality. Choice B is incorrect as the condition is not linked to a single segment found only on the Y chromosome. Choice D is unrelated as it mentions a decrease in estrogen levels, which is not a cause of sickle-cell anemia.
If an individual receives a recessive gene for eye color from both parents, the:
- A. gender of the child will not determine the expression of that trait.
- B. recessive trait will be expressed in the child.
- C. recessive trait will be expressed in all the offspring.
- D. recessive trait will be suppressed, and the dominant trait will not be expressed.
Correct Answer: B
Rationale: When an individual inherits a recessive gene for eye color from both parents, the recessive trait will be expressed in the child. This is because having two copies of the recessive gene overrides the presence of any dominant gene. Choice A is incorrect because the expression of the trait is determined by the genetic makeup, not the gender of the child. Choice C is incorrect as the expression of the recessive trait is certain when both parents pass on the recessive gene, but it does not mean that all offspring will express the trait. Choice D is incorrect because if both parents provide a recessive gene, the dominant trait will not be expressed in the child, but it does not mean it will be suppressed; rather, the recessive trait will be expressed.