Nokea
A new client's pregnancy is confirmed at 10 weeks gestation. Her history reveals that her first two pregnancies ended in spontaneous abortion at 12 and 20 weeks. She has a 4-year-old and a set of 1-year-old twins. How should the nurse record the client's current gravida and para status?
- A. Gravida 2, para 3
- B. Gravida 4, para 2
- C. Gravida 5, para 2
- D. Gravida 5, para 4
Correct Answer: C
Rationale: The correct answer is C: Gravida 5, para 2. Gravida refers to the total number of pregnancies, including the current one. The client is currently pregnant (1), had two spontaneous abortions (2), a 4-year-old (3), and a set of 1-year-old twins (4-5). Para refers to the number of viable births (past the age of viability). The client has a 4-year-old and a set of 1-year-old twins, totaling 2 live births. Therefore, the correct status is Gravida 5, para 2.
Choice A (Gravida 2, para 3) is incorrect because it does not account for the client's current pregnancy and the twins. Choice B (Gravida 4, para 2) is incorrect as it overlooks the client's previous spontaneous abortions. Choice D (Gravida 5, para 4) is incorrect as it includes all
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A nurse is performing a physical assessment of a newborn. Which of the following clinical findings should the nurse expect? (Select all that apply).
- A. Heart Rate 154/min
- B. Axillary temperature 96.8 F
- C. Respiratory rate 58/min
- D. Length 43 cm (16.9in)
Correct Answer: A,B,C,D
Rationale: The correct answer is A, B, C, and D.
1. Heart rate of 154/min is expected in a newborn, indicating normal cardiac function.
2. Axillary temperature of 96.8 F is within the normal range for a newborn.
3. Respiratory rate of 58/min is expected due to the newborn's immature respiratory system.
4. Length of 43 cm (16.9 in) falls within the normal range for a newborn's size.
Incorrect choices are not applicable due to lack of details, but in general, incorrect options would have included values outside the normal range for a newborn's physical assessment.
A nurse is caring for a client and her partner who have experienced a fetal death. Which of the following actions should the nurse take?
- A. Take photos of the newborn to give to the parents.
- B. Tell the parents that they can consider organ donations.
- C. Encourage the parents to avoid allowing older children to visit them in the hospital.
- D. Explain to the parents the need to name the newborn.
Correct Answer: A
Rationale: The correct answer is A because taking photos of the newborn allows the parents to create lasting memories and helps in the grieving process. It also validates the existence of the baby as a member of the family. Choice B may be insensitive as it might be too soon to discuss organ donation. Choice C may isolate the parents from their support system. Choice D may pressure the parents at a difficult time.
A nurse is preparing to admit a 15-year-old client with HIV/AIDS. Based on the client's diagnosis, which of the following nursing actions is appropriate?
- A. Contribute to planning client education on standard precautions in age-appropriate manner.
- B. Contact the dietary department to request foods be delivered on disposable dishes.
- C. Prepare for infection control in a negative pressure room for this client.
- D. Instruct visitors to wear gowns and masks when entering the client's room.
Correct Answer: A
Rationale: Correct Answer: A
Rationale:
1. Client education on standard precautions is crucial to prevent the spread of infections.
2. The nurse should tailor the education in an age-appropriate manner to ensure understanding.
3. Contributing to planning education empowers the client to take an active role in their health.
4. This action promotes client safety and reduces the risk of transmission to others.
Summary:
B: Contacting the dietary department for disposable dishes is not directly related to HIV/AIDS education or infection control.
C: Preparing a negative pressure room is not necessary for standard precautions and may not be feasible in all settings.
D: Instructing visitors to wear gowns and masks is excessive for standard precautions and may cause distress to the client.
A nurse is caring for a client who is 36 weeks of gestation and has a prescription for an amniocentesis. For which of the following reasons should the nurse prepare the client for an ultrasound?
- A. To estimate fetal weight
- B. To locate a pocket of fluid
- C. To determine multiparity
- D. To pre-screen for fetal anomalies
Correct Answer: B
Rationale: The correct answer is B: To locate a pocket of fluid. Before performing an amniocentesis procedure, it is essential to locate a pocket of amniotic fluid to ensure the safety of the fetus during the procedure. This is crucial to avoid accidentally puncturing the fetus or placenta. An ultrasound helps in visualizing the amniotic fluid pocket and guiding the needle insertion accurately.
Incorrect Choices:
A: To estimate fetal weight - Estimating fetal weight is not a primary reason for preparing the client for an ultrasound before amniocentesis.
C: To determine multiparity - Multiparity (number of pregnancies) does not directly impact the need for an ultrasound before an amniocentesis.
D: To pre-screen for fetal anomalies - While ultrasounds can detect anomalies, the primary purpose before an amniocentesis is to locate the amniotic fluid pocket, not screen for anomalies.
A nurse is reinforcing teaching with the parent of an infant who has club feet with bilateral casts.
- A. "Check the toes for any swelling or discoloration."'
- B. "Monthly recasting should be scheduled with the orthopedist."'
- C. "Use a heated fan or dryer to facilitate the drying of the cast."'
- D. "Give the baby Tylenol every 4 hr to help with pain."'
Correct Answer: A
Rationale: The correct answer is A because checking the toes for swelling or discoloration is crucial in monitoring circulation and preventing complications like pressure sores. Choice B is incorrect as casts are typically changed more frequently. Choice C is incorrect as heat can cause burns. Choice D is incorrect as giving Tylenol every 4 hours without a physician's recommendation is not advisable for pain management in infants.