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: A platelet count of 60,000/mm3 is significantly low and can be indicative of thrombocytopenia, a potential complication of preeclampsia known as HELLP syndrome (Hemolysis, Elevated Liver enzymes, and Low Platelet count). Thrombocytopenia increases the risk of bleeding complications during pregnancy and delivery, requiring prompt evaluation and management by the healthcare provider. The nurse should report this finding immediately to prevent any adverse outcomes for the client and baby.
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The primiparous patient that's 40 weeks' gestation reports to the nurse that she has increased pelvic pressure and increased urinary frequency. Which response by the nurse is best?
- A. This symptom usually means the baby's head has descended further
- B. Unless you have pain with urination, we don't need to worry it
- C. Come in for an appointment today and we'll check out everything
- D. This might indicate that the baby is no longer in a head down position
Correct Answer: A
Rationale: The best response by the nurse is to reassure the primiparous patient that her increased pelvic pressure and urinary frequency could mean that the baby's head has descended further into the pelvis. This can indicate that labor is approaching, as the baby is getting into position for birth. It is important for the nurse to provide this information to ease the patient's concerns and help her understand the potential significance of these symptoms at 40 weeks' gestation.
Which of the following actions is appropriate for the nurse to take regarding a 9-year-old girl diagnosed with gonorrhea?
- A. Notify the physician so the child can be admitted to the hospital.
- B. Discuss with the girl the need to stop future sexual encounters.
- C. Question the mother about her daughter's menstrual history.
- D. Report the girl's medical findings to child protective services.
Correct Answer: D
Rationale: Gonorrhea in a 9-year-old girl is highly suggestive of sexual abuse, which requires reporting to child protective services.
The nurse is assessing a client with hyperemesis gravidarum. What finding requires immediate intervention?
- A. Urine output of 50 mL/hr.
- B. Weight loss of 5 pounds in 2 weeks.
- C. Dry mucous membranes and poor skin turgor.
- D. Nausea relieved by eating crackers.
Correct Answer: C
Rationale: Dehydration, indicated by dry mucous membranes and poor skin turgor, requires immediate intervention in hyperemesis gravidarum.
What advice should the nurse give if a woman forgets to take a low-dose combination birth control pill?
- A. Take it as soon as she remembers, even if that means taking two pills in one day.
- B. Skip that pill and refrain from intercourse for the remainder of the month.
- C. Wear a pad for the next week because she will experience vaginal bleeding.
- D. Take an at-home pregnancy test at the end of the month to check for a pregnancy.
Correct Answer: A
Rationale: Taking the missed pill promptly minimizes contraceptive failure.
What is the nurse's role in supporting breastfeeding for a first-time mother?
- A. Provide formula supplements
- B. Demonstrate proper latching techniques
- C. Recommend stopping breastfeeding
- D. Provide pacifiers to prevent overfeeding
Correct Answer: A
Rationale: Proper latching techniques help establish successful breastfeeding and prevent complications.