Nokea
A multigravid client is admitted at 16 weeks' gestation with a diagnosis of hyperemesis gravidarum. The nurse should explain to the client that hyperemesis gravidarum is thought to be related to high levels of which of the following hormones?
- A. Progesterone.
- B. Estrogen.
- C. Somatotropin.
- D. Aldosterone.
Correct Answer: B
Rationale: High estrogen levels are associated with hyperemesis gravidarum.
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Which of the following would be most important for the nurse to encourage in a primiparous client diagnosed with endometritis who is receiving intravenous antibiotic therapy?
- A. Ambulate to the bathroom frequently.
- B. Discontinue breast-feeding temporarily.
- C. Maintain bed rest in Fowler's position.
- D. Restrict visitors to prevent contamination.
Correct Answer: C
Rationale: Fowler's position promotes drainage of uterine secretions, aiding recovery from endometritis.
A woman who is Rh-negative has delivered an Rh-positive infant. The nurse explains to the client that she will receive RhoGAM. The nurse determines that the client understands the purpose of RhoGAM when she states:
- A. "RhoGAM will protect my next baby if it is Rh-negative."
- B. "RhoGAM will prevent antibody formation in my blood."
- C. "RhoGAM will be given to prevent German measles."
- D. "RhoGAM will be used to prevent bleeding in my newborn."
Correct Answer: B
Rationale: RhoGAM prevents maternal antibody formation against Rh-positive blood.
The nurse is receiving over the telephone a laboratory results report of a neonate's blood glucose level. The nurse should:
- A. Write the results in the chart, and receive confirmation from the caller that the nurse understands the results.
- B. Repeat the results to the caller from the laboratory, write the results on scrap paper first, and then transfer the results to the chart.
- C. Indicate to the caller that the nurse cannot receive verbal results from laboratory tests for neonates, and ask the laboratory to bring the written results to the nursery.
- D. Request that the laboratory send the results by email to transfer to the client's electronic record.
Correct Answer: A
Rationale: Writing the results and confirming with the caller ensures accuracy and compliance with documentation protocols.
The nurse is assessing fetal presentation in a multiparous client. The illustration below indicates which of the following types of presentation?
- A. Frank breech.
- B. Complete breech.
- C. Footling breech.
- D. Vertex.
Correct Answer: D
Rationale: Without the illustration, the context suggests a typical presentation for a multiparous client, which is most likely vertex (head-down), the most common and favorable for vaginal delivery.
A multiparous client at 24 hours postpartum demonstrates a positive Homan's sign with discomfort. The nurse should:
- A. Place a cold pack on the client's perineal area.
- B. Place the client in a semi-Fowler's position.
- C. Notify the client's physician immediately.
- D. Ask the client to ambulate around the room.
Correct Answer: C
Rationale: A positive Homan's sign suggests possible deep vein thrombosis, requiring immediate physician notification.