Nokea
A nurse is assessing a client who gave birth 12 hr ago and is experiencing excessive vaginal bleeding. Which of the following findings indicates the client is experiencing decreased cardiac output?
- A. Bradycardia
- B. Flushed face
- C. Hypotension
- D. Polyuria
Correct Answer: C
Rationale: Hypotension is a key indicator of decreased cardiac output, especially in the context of postpartum hemorrhage, which can lead to significant fluid volume loss and compromise perfusion.
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A client tells the nurse that she suspects she is pregnant because she is able to feel the baby move. The nurse knows that this is a:
- A. Presumptive sign of pregnancy
- B. Probable sign of pregnancy
- C. Positive sign of pregnancy
- D. Possible sign of pregnancy
Correct Answer: A
Rationale: Quickening, or the sensation of fetal movement, is considered a presumptive sign of pregnancy. It is not definitive because other conditions, such as gas or intestinal movement, can mimic the feeling of fetal movement.
A nurse is teaching a client who is Rh-negative about Rh (D) immune globulin. Which of the following statements by the client indicates an understanding of the teaching?
- A. If my partner is Rh-negative, I will not receive the shot.
- B. I will receive the shot after delivery if my baby is Rh-negative.
- C. I should not receive any immunizations for 3 months after the shot.
- D. This shot may be given after birth to protect future pregnancies.
Correct Answer: D
Rationale: The client's statement correctly reflects that Rh immune globulin is administered after delivery to prevent sensitization in future pregnancies, especially if the baby is Rh-positive.
A nurse is caring for a client who is in active labor and notes late decelerations in the FHR on the external fetal monitor. Which of the following actions should the nurse take first?
- A. Change the client's position
- B. Palpate the uterus to assess for tachysystole
- C. Increase the client's IV infusion rate
- D. Administer oxygen at 10 L/min via nonrebreather mask
Correct Answer: A
Rationale: The first action should be to change the client's position, as this can relieve pressure on the umbilical cord and improve fetal oxygenation, addressing the cause of late decelerations.
A nurse is caring for a client who is experiencing preterm labor and has a new prescription for terbutaline. Which of the following findings is a contraindication for administration of this medication?
- A. Heart disease
- B. Cervical dilation of 2 cm
- C. Gestational age of 34 weeks
- D. Allergy to penicillin
Correct Answer: A
Rationale: Terbutaline is contraindicated in clients with heart disease due to the risk of tachycardia and other cardiac complications associated with beta-agonists.
During a breast examination on a 24-year-old client the nurse notes the following findings. Which finding is of most concern and should be reported to the provider?
- A. An irregularly shaped, nontender lump is palpable in the right breast
- B. Tenderness is present during menstruation
- C. Bilateral, symmetrical lumps that move with palpation
- D. The client reports breast tenderness before menstruation
Correct Answer: A
Rationale: An irregularly shaped, nontender lump is a concerning finding because it may indicate breast cancer. The nurse should report this finding to the provider for further investigation.