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Client reports feeling well, findings include: General: No acute distress. Cardiovascular: No murmur or rub. Respiratory: Bilateral breath sounds clear. Abdomen: Fundal height 38 cm. Genitourinary: Purulent cervical discharge.
A nurse conducts a physical exam of a client who reports feeling well. Which finding requires clinical intervention?
- A. No acute distress.
- B. No murmur or rub.
- C. Bilateral breath sounds clear.
- D. Fundal height 38 cm.
- E. Purulent cervical discharge.
Correct Answer: E
Rationale: Purulent cervical discharge suggests an ongoing infection, likely bacterial cervicitis. It reflects leukocyte accumulation due to pathogenic invasion, requiring clinical intervention to prevent complications.
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Newborn whose mother had gestational diabetes mellitus.
A nurse is assessing a newborn whose mother had gestational diabetes mellitus. Which of the following findings should the nurse identify as a manifestation of hypoglycemia?
- A. Jitteriness.
- B. Hypertonia.
- C. Acrocyanosis of the hands.
- D. Generalized petechiae.
Correct Answer: A
Rationale: Jitteriness indicates hypoglycemia in newborns as glucose is critical for neonatal brain function. Blood glucose less than 45 mg/dL supports this diagnosis, requiring prompt intervention to avoid neurological harm.
Client who is Rh-negative.
A nurse is teaching a pregnant client who is Rh-negative about Rho(D) immune globulin. Which of the following statements by the client indicates an understanding of the teaching?
- A. This shot may be given after birth to protect future pregnancies.
- B. If my partner is Rh-negative, I will not receive the shot.
- C. I will receive the shot after delivery if my baby is Rh-negative.
- D. I should not receive any immunizations for 3 months after the shot.
Correct Answer: A
Rationale: Rho(D) immune globulin administered postpartum prevents maternal sensitization to Rh-positive fetal blood cells, reducing risks of hemolytic disease in subsequent pregnancies by suppressing maternal immune response.
Client receiving oxytocin to augment labor, nurse notes recurrent variable decelerations of the FHR.
A nurse is caring for a client who is receiving oxytocin to augment labor. The nurse notes recurrent variable decelerations of the FHR. Which of the following actions should the nurse take first?
- A. Prepare the necessary equipment to initiate an amnioinfusion.
- B. Assist with performing a vaginal/speculum exam to check for a prolapsed umbilical cord.
- C. Discontinue the infusion of oxytocin.
- D. Provide instructions for the client about potential preparation for birth.
Correct Answer: C
Rationale: Discontinuing oxytocin reduces uterine contractions, alleviating cord compression and improving fetal oxygenation, which is the first step in managing recurrent variable decelerations of fetal heart rate.
Drag words from the choices below to fill in each blank in the following sentence: The nurse should [option] as a potential complication.
- A. The nurse should plan to discuss with the client the risk for hypothyroidism.
- B. The nurse should include fallopian tube rupture as a potential complication.
- C. The nurse should explain hypovolemic shock as a life-threatening risk.
- D. The nurse should elaborate on the development of an invasive mole.
Correct Answer: B
Rationale: Fallopian tube rupture is a critical complication of conditions like ectopic pregnancy, emphasizing the importance of timely diagnosis and intervention to prevent life-threatening internal bleeding and sepsis.
Client gave birth 1 week ago, states: 'I don't know what's wrong. I love my baby, but I feel so let down and I seem to cry for no reason.'
A nurse is assessing a client who gave birth 1 week ago. The client states, 'I don't know what's wrong. I love my baby, but I feel so let down and I seem to cry for no reason.' The nurse should identify that the client is experiencing which of the following emotional responses to birth?
- A. Postpartum depression.
- B. Taking-in phase.
- C. Postpartum blues.
- D. Taking-hold phase.
Correct Answer: C
Rationale: Postpartum blues, characterized by mood swings, crying spells, and irritability, typically resolve within two weeks postpartum and are linked to hormonal changes.