Nokea
A nurse is assessing a client who is at 27 weeks of gestation and has preeclampsia. Which of the following findings should the nurse report to the provider?
- A. Urine protein concentration 200 mg/ 24 hr
- B. Creatinine 0.8 mg/ dL
- C. Hemoglobin 14.8 g/ dL
- D. Platelet Count 60.000/ mm3
Correct Answer: D
Rationale: The correct answer is D: Platelet Count 60,000/mm3. In preeclampsia, low platelet count can indicate thrombocytopenia, a serious complication that can lead to bleeding. This finding requires immediate attention to prevent severe complications like hemorrhage or organ damage.
A: Urine protein concentration within normal range for preeclampsia.
B: Creatinine within normal range, not a priority in this scenario.
C: Hemoglobin within normal range, not a priority in this scenario.
You may also like to solve these questions
A nurse is reviewing the laboratory results for a newborn 12 hours old. Which of the following is an expected findings.
- A. Glucose 40mg/dl
- B. WBC 6000
- C. Hemoglobin 12
- D. Platelets 80000
Correct Answer: A
Rationale: The correct answer is A: Glucose 40mg/dl. In newborns, normal glucose levels range from 40-60mg/dl. This level is expected to be lower in the immediate postnatal period due to the transition from placental to independent glucose regulation. WBC count of 6000 is within normal range. Hemoglobin at 12 is normal for a newborn. Platelets of 80000 are low and could indicate a potential issue, such as thrombocytopenia, which would require further investigation.
A nurse is caring for a client following a vaginal delivery of a term fetal demise. Which of the following statement should the nurse make?
- A. “You can bathe and dress your baby if you’d like to.”
- B. “If you don’t hold the baby, it will make letting go much harder.”
- C. “You should name the baby so she can have an identity.”
- D. “I’m sure you will be able to have another baby when you’re ready.”
Correct Answer: A
Rationale: The correct answer is A, as it encourages the client to make decisions based on their preferences. By stating, "You can bathe and dress your baby if you’d like to," the nurse offers support and control to the client during a difficult time. This empowers the client to engage in meaningful rituals and take control of the situation.
Choice B is incorrect because it imposes guilt on the client by suggesting that not holding the baby will make letting go harder, which may not be the case for everyone. Choice C is incorrect as naming the baby should be a personal decision and not a directive from the nurse. Choice D is incorrect because it assumes the client's readiness for another baby, which may not be the case and can be insensitive.
A nurse is providing discharge instructions to a client who is breastfeeding her newborn.
- A. Expect 2 to 4 wet diapers every 24 hours
- B. Allow the baby to feed at least every 3 hours
- C. Offer the newborn 30 mL (1 oz.) of water between feedings
- D. Feed the newborn 5 to 10 minutes per breast
Correct Answer: B
Rationale: The correct answer is B: Allow the baby to feed at least every 3 hours. This is important for maintaining the baby's hydration, ensuring proper nutrition, and promoting successful breastfeeding. Feeding on demand helps establish a good milk supply and supports the baby's growth and development. Offering water (choice C) is unnecessary and can interfere with breastfeeding. Limiting feeding time to 5-10 minutes per breast (choice D) can prevent the baby from getting enough hindmilk, which is rich in fat and important for weight gain. Expecting 2-4 wet diapers every 24 hours (choice A) is a general guideline but not as crucial as ensuring frequent feedings for a breastfeeding newborn.
A nurse on postpartum unit caring for four clients. Which of the following clients should receive Rh, (D) Immune globulin to prevent Rh- is immunization?
- A. An Rh-negative mother who has an Rh- positive infant
- B. An Rh –positive mother who has an Rh- negative infant
- C. An Rh-positive mother who has an Rh- positive infant
- D. An Rh- negative mother who has an Rh- negative infant
Correct Answer: A
Rationale: The correct answer is A: An Rh-negative mother who has an Rh-positive infant. This mother is at risk for developing Rh isoimmunization, a condition where her immune system attacks the Rh-positive red blood cells of her infant, potentially causing harm in future pregnancies. Rh(D) Immune globulin is given to prevent this by blocking the mother's immune response to the Rh-positive cells of the infant. The other choices do not require Rh(D) Immune globulin because they do not involve the risk of Rh isoimmunization. Choice B involves an Rh-positive mother who is not at risk of isoimmunization. Choice C involves an Rh-positive mother with an Rh-positive infant, so there is no incompatibility. Choice D involves an Rh-negative mother with an Rh-negative infant, so there is no risk of isoimmunization.
A nurse is planning care for a client who is scheduled for a cesarian birth. Which of the following interventions should the nurse include in the plan of care?
- A. Instruct the client not to eat after midnight the night before
- B. Perform a surgical time out
- C. Shave the client’s abdomen at the preoperative visit
- D. Secure the clients hair to their scalp with metal hair pins
Correct Answer: B
Rationale: The correct answer is B: Perform a surgical time out. This step is crucial before any surgical procedure, including a cesarean birth, to ensure patient safety. During the time out, the surgical team verifies the patient's identity, correct procedure, correct site, and other essential details to prevent errors. In contrast, choice A is outdated practice as current guidelines allow clear fluids up to a few hours before surgery. Choice C is unnecessary and can increase the risk of infection. Choice D is incorrect as metal hairpins are not recommended due to the risk of injury and interference with surgical equipment.