Nokea
A laboring client's membranes rupture spontaneously. The nurse notices that the amniotic fluid is greenish-brown. What intervention should the nurse implement first?
- A. Turn the client to her left side
- B. Contact the healthcare provider
- C. Assess the fetal heart rate
- D. Check the cervical dilation
Correct Answer: C
Rationale: The correct answer is to assess the fetal heart rate. When amniotic fluid is greenish-brown, it may indicate the presence of meconium, which can be concerning as it may lead to fetal distress. Assessing the fetal heart rate will help determine the well-being of the fetus and guide further actions to ensure the safety of both the mother and the baby.
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A couple has been trying to conceive for nine months without success. Which information obtained from the clients is most likely to have an impact on the couple's ability to conceive a child?
- A. Both partners have a daily exercise regimen that includes running four miles each morning.
- B. The couple has a history of having sexual intercourse 2 to 3 times per week.
- C. The woman's menstrual period occurs every 35 days.
- D. They use lubricants with each sexual encounter to decrease friction.
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The nurse is caring for a 2-day old neonate who has not passed meconium and has a swollen abdomen. The healthcare provider reviews the flat plate X-ray of the abdomen and makes a tentative diagnosis of Hirschsprung's disease. Which pathophysiological process is consistent with this neonate's clinical picture?
- A. The congenital absence of parasympathetic ganglion cells to large intestine produces no peristalsis.
- B. Pyloric obstruction causes reflux and projectile hematemesis.
- C. Partial imperforated anal opening limits passage of stools.
- D. Peristalsis moving against the intestinal obstruction causing hyperactivity of the bowel.
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
One hour after giving birth to an 8-pound infant, a client's lochia rubra has increased from small to large, and her fundus is boggy despite massage. The client's pulse is 84 beats/minute, and blood pressure is 156/96. The healthcare provider prescribes Methergine 0.2 mg IM 1. What action should the healthcare provider take immediately?
- A. Give the medication as prescribed and monitor for efficacy.
- B. Encourage the client to breastfeed rather than bottle-feed.
- C. Have the client empty her bladder and massage the fundus.
- D. Call the healthcare provider to question the prescription.
Correct Answer: D
Rationale: The correct action for the healthcare provider to take immediately is to call the healthcare provider to question the prescription. Methergine is contraindicated in clients with hypertension due to its potential to elevate blood pressure further. In this scenario, the client's blood pressure is already elevated at 156/96, making it unsafe to administer Methergine. The LPN/LVN should advocate for the client's safety by questioning the prescription to prevent potential harm.
During an examination for possible cryptorchidism in an infant, what technique should be used?
- A. Place the infant in a warm room and use a calm approach.
- B. Hold the scrotum and palpate gently.
- C. Cleanse the penis with an antiseptic-soaked pad.
- D. Position the infant in a warm room to prevent muscle contraction.
Correct Answer: D
Rationale: When examining an infant for cryptorchidism, it is important to position the infant in a warm room to prevent muscle contraction, which could cause the testes to retract. Placing the infant in a side-lying position may not be necessary for this specific examination. Holding the penis or retracting the foreskin is not relevant to the assessment for cryptorchidism. Cleansing the penis with an antiseptic pad is not indicated for this examination.
What should the nurse recommend to a woman with mastitis?
- A. Apply heat to the affected area.
- B. Apply cold compresses to the affected area.
- C. Use a breast pump to express milk.
- D. Continue breastfeeding as usual.
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.