Nokea
A client reports an intermittent dark brown vaginal discharge for the past three days. What should the nurse do?
- A. The nurse should assess the client for signs of molar pregnancy.
- B. The nurse should evaluate the risk for hypovolemic shock due to blood loss.
- C. The nurse should ensure appropriate laboratory testing for the diagnosis of choriocarcinoma.
- D. The nurse should prioritize preparing the client for suction and curettage.
Correct Answer: A
Rationale: Molar pregnancy often manifests as intermittent dark brown vaginal discharge due to trophoblastic tissue expulsion. It warrants assessment as it correlates with hCG elevation and abnormal placental development.
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A nurse is teaching the parents of a newborn how to care for their child's uncircumcised penis. Which of the following instructions should the nurse include?
- A. Retract the foreskin until you feel resistance.
- B. Use a cotton swab to clean under the foreskin.
- C. Apply petroleum jelly to the foreskin.
- D. Wash the penis once per day with soap and water.
Correct Answer: D
Rationale: Daily washing with mild soap and water ensures proper hygiene and prevents infection. This method maintains cleanliness without causing harm to sensitive tissues.
Which of the following findings should the nurse identify as manifestations of the newborn's suspected condition?
- A. Mother's report of feedings.
- B. Oral mucosa findings.
- C. Respiratory findings.
- D. Temperature change.
Correct Answer: B,C
Rationale: Oral mucosa changes (B), such as pallor or cyanosis, may occur due to hypoxia or circulatory compromise. Respiratory changes (C), including tachypnea or retractions, are significant manifestations of stress or pulmonary involvement in neonatal conditions like asphyxia.
A nurse is admitting a client who is at 33 weeks of gestation and has preeclampsia with severe features. Which of the following actions should the nurse take?
- A. Restrict protein intake to less than 40 g/day.
- B. Initiate seizure precautions for the client.
- C. Encourage the client to ambulate twice per day.
- D. Initiate an infusion of 0.9% sodium chloride at 150 mL/hr.
Correct Answer: B
Rationale: Seizure precautions are necessary in preeclampsia due to the risk of eclampsia from uncontrolled blood pressure. Measures include bedrails padding and medication administration to reduce seizure occurrences.
Drag words from the choices below to fill in each blank in the following sentence: The nurse should [option] as a potential complication.
- A. The nurse should plan to discuss with the client the risk for hypothyroidism.
- B. The nurse should include fallopian tube rupture as a potential complication.
- C. The nurse should explain hypovolemic shock as a life-threatening risk.
- D. The nurse should elaborate on the development of an invasive mole.
Correct Answer: B
Rationale: Fallopian tube rupture is a critical complication of conditions like ectopic pregnancy, emphasizing the importance of timely diagnosis and intervention to prevent life-threatening internal bleeding and sepsis.
A nurse is caring for a client who gave birth 4 hr ago and is experiencing excessive vaginal bleeding. Which of the following actions should the nurse plan to take first?
- A. Elevate the client's legs to a 30° angle.
- B. Insert an indwelling urinary catheter.
- C. Massage the client's fundus.
- D. Initiate an infusion of oxytocin.
Correct Answer: C
Rationale: Massaging the fundus promotes uterine contraction, which is the first-line intervention to control postpartum hemorrhage caused by uterine atony.