Nokea
A gravida II para 0 is admitted to the labor and delivery unit. The doctor performs an amniotomy. Which observation would the nurse expect to make immediately after the amniotomy?
- A. Fetal heart tones 160 beats per minute
- B. A moderate amount of clear fluid
- C. A small amount of greenish fluid
- D. A small segment of the umbilical cord
Correct Answer: B
Rationale: A moderate amount of clear amniotic fluid is expected after an amniotomy, indicating normal rupture of membranes.
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A client who was prescribed increasing dosages of baclofen to relieve muscle spasms should have taken 80 mg daily in 4 divided doses but misunderstood and took 80 mg four times a day, resulting in an overdose and pronounced CNS depression. Which of the following treatments does the nurse anticipate?
- A. Administration of naloxone.
- B. Administration of atropine.
- C. Supportive care only.
- D. Administration of flumazenil.
Correct Answer: C
Rationale: Baclofen overdose causes CNS depression, treated with supportive care (C) like ventilation and monitoring. Naloxone (A), atropine (B), and flumazenil (D) are not antidotes for baclofen.
The nurse is developing a care plan for a client with hepatitis A. The nurse knows that the primary routes of transmission of this hepatitis virus are which of the following? Select all that apply.
- A. sputum
- B. blood
- C. feces
- D. contaminated food
Correct Answer: C,D
Rationale: Hepatitis A is transmitted primarily via the fecal-oral route, through contaminated food or water (D) and feces (C).
A patient with hypothyroidism states that she takes Synthroid® 0.112 mg daily, but the pharmacy has issued the drug labeled in micrograms. How many micrograms of Synthroid® is equivalent to 0.112 mg? Record your answer using a whole number.
Correct Answer: 112
Rationale: To convert milligrams to micrograms, multiply by 1,000: 0.112 mg X 1,000 = 112 micrograms.
Which statement by the client regarding sickle cell disease indicates a need for further teaching?
- A. I should avoid strenuous exercise.
- B. I can enjoy one glass of red wine per day.
- C. I will avoid cigarettes and all tobacco products.
- D. I should avoid traveling to places at high altitudes such as Denver.
Correct Answer: B
Rationale: Alcohol, including red wine, can cause dehydration and increase the risk of sickle cell crisis, so it should be avoided. Other statements are correct.
The physician has made a diagnosis of 'shaken child' syndrome for a 13-month-old who was brought to the emergency room after a reported fall from his highchair. Which finding supports the diagnosis of 'shaken child' syndrome?
- A. Fracture of the clavicle
- B. Periorbital bruising
- C. Retinal hemorrhages
- D. Fracture of the humerus
Correct Answer: C
Rationale: Retinal hemorrhages are a hallmark of shaken baby syndrome due to the shearing forces from violent shaking causing bleeding in the retina.