Nokea
A nurse in a prenatal clinic is assessing a group of clients. Which of the following clients should the nurse see first?
- A. A client who is at 11 weeks of gestation and reports abdominal cramping.
- B. A client who is at 15 weeks of gestation and reports tingling and numbness in right hand.
- C. A client who is at 20 weeks of gestation and reports constipation for the past 4 days.
- D. A client who is at 8 weeks of gestation and reports having three bloody noses in the past week.
Correct Answer: A
Rationale: Abdominal cramping in early pregnancy can be a sign of a miscarriage or ectopic pregnancy, both of which require immediate evaluation and intervention.
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A nurse is reviewing the medical record of a client who had a vaginal delivery 3 hr ago. Which of the following findings place the client at risk for postpartum hemorrhage? (Select all that apply.)
- A. Labor induction with oxytocin
- B. Newborn weight 2.948 kg (6 lb 8 oz)
- C. Vacuum-assisted delivery
- D. History of uterine atony
- E. History of human papillomavirus
Correct Answer: A,C,D
Rationale: The correct answers are A, C, and D.
A: Labor induction with oxytocin can lead to uterine hyperstimulation, increasing the risk of postpartum hemorrhage.
C: Vacuum-assisted delivery can cause trauma to the birth canal, leading to increased bleeding.
D: History of uterine atony indicates a weak uterine muscle tone, which can result in excessive bleeding after delivery.
B: Newborn weight is not directly related to postpartum hemorrhage risk.
E: History of human papillomavirus does not increase the risk of postpartum hemorrhage.
Which of the following is a potential ethical issue related to neonatal organ donation?
- A. Informed consent
- B. Allocation of resources
- C. End-of-life decision making
- D. All of the above
Correct Answer: A
Rationale: Informed consent is a key ethical issue in neonatal organ donation.
A nurse is caring for a client who is at 10 weeks of gestation. Which of the following findings should the nurse report to the provider?
- A. Frequent vomiting with weight loss of 3 lb in 1 week
- B. Reports of mood swings
- C. Nosebleeds occurring approximately 3 times per week
- D. Increased vaginal discharge
Correct Answer: A
Rationale: The correct answer is A. Frequent vomiting with weight loss of 3 lb in 1 week is concerning during the first trimester as it may indicate hyperemesis gravidarum, a severe form of morning sickness that can lead to dehydration and malnutrition, posing risks to both the mother and the fetus. The nurse should report this finding to the provider for further evaluation and intervention.
Incorrect choices:
B: Reports of mood swings are common during pregnancy due to hormonal changes and are not typically a cause for concern at 10 weeks of gestation.
C: Nosebleeds are common in pregnancy due to increased blood volume and hormonal changes and are usually not serious unless severe or frequent.
D: Increased vaginal discharge is a normal pregnancy symptom caused by hormonal changes and increased blood flow to the pelvic area.
A nurse is admitting a client who is 1 week postpartum and reports excessive vaginal bleeding. The nurse speaks a different language than the client. The client's partner and 10-year-old child are accompanying her. Which of the following actions should the nurse take to gather the client's admission data?
- A. Have the client's child translate.
- B. Ask a nursing student who speaks the same language as the client to translate.
- C. Request a female interpreter through the facility
- D. Allow the client's partner to translate.
Correct Answer: C
Rationale: Requesting a female interpreter through the facility ensures accurate and professional communication, respecting the client's privacy and cultural preferences. Using a child or partner to translate is inappropriate and may lead to misunderstandings.
Which of the following findings should the nurse report to the provider? (Select all that apply.)
- A. Coombs test result
- B. Mucous membrane assessment
- C. Intake and output
- D. Respiratory rate
- E. Head assessment finding
- F. Heart rate
- G. Sclera color
Correct Answer: A,B,C,G
Rationale: