Nokea
A multigravid client diagnosed with a probable ruptured ectopic pregnancy is scheduled for emergency surgery. In addition to monitoring the client's blood pressure before surgery, which of the following would the nurse assess?
- A. Uterine cramping.
- B. Abdominal distention.
- C. Hemoglobin and hematocrit.
- D. Pulse rate.
Correct Answer: D
Rationale: Pulse rate helps assess circulatory status.
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The nurse is making clinical rounds on a group of clients in a newborn nursery. Which infant is at greatest risk of developing respiratory distress syndrome (RDS)?
- A. A neonate born at 36 weeks' gestation.
- B. A neonate born by Cesarean section.
- C. A neonate experiencing apneic episodes.
- D. A neonate who is 42 weeks' gestation.
Correct Answer: C
Rationale: A neonate experiencing apneic episodes is at greatest risk for RDS due to compromised respiratory function.
A multiparous client who has a neonate diagnosed with hemolytic disease of the newborn asks the nurse why the neonate has developed this problem. Which of the following responses by the nurse should be most appropriate?
- A. You are Rh-positive and the neonate's father is Rh-negative.'
- B. You and the neonate's father are both Rh-negative.'
- C. You are Rh-negative and the neonate's father is Rh-positive.'
- D. The fetus is Rh-negative and you are Rh-positive.'
Correct Answer: C
Rationale: Hemolytic disease of the newborn occurs when an Rh-negative mother carries an Rh-positive fetus, leading to maternal antibody production against fetal red blood cells.
To determine whether a primigravid client in labor with a fetus in the left occipitoanterior (LOA) position is completely dilated, the nurse performs a vaginal examination. During the examination the nurse should palpate which of the following cranial sutures?
- A. Sagittal.
- B. Lambdoidal.
- C. Coronal.
- D. Frontal.
Correct Answer: A
Rationale: In the LOA position, the fetus's occiput is anterior, and the sagittal suture (running midline along the skull) is most accessible during vaginal examination to assess dilation and fetal position. Other sutures are less prominent in this presentation.
A client asks about the disadvantages of the contraceptive sponge. Which of the following would the nurse include?
- A. It is difficult to insert and remove.
- B. It provides protection against STIs.
- C. It can be left in place for up to 48 hours.
- D. It is highly effective for women who have given birth.
Correct Answer: A
Rationale: The contraceptive sponge can be difficult to insert and remove, especially for some users. It does not protect against STIs, can be left in place for up to 24 hours (not 48), and is less effective for women who have given birth due to changes in vaginal anatomy.
Which of the following actions should the nurse take when performing external cardiac massage on a neonate born at 28 weeks' gestation?
- A. Alternate cardiac massage with ventilation.
- B. Compress the sternum with the palm of the hand.
- C. Compress the chest 70 to 80 times per minute.
- D. Displace the chest 70 to 80 times per minute.
Correct Answer: A
Rationale: Alternating cardiac massage with ventilation follows neonatal resuscitation guidelines to restore circulation and oxygenation.