Nokea
A nurse is assessing a client who is postpartum and has idiopathic thrombocytopenia purpura (ITP). Which of the following findings should the nurse expect?
- A. Decreased platelet count.
- B. Increased erythrocyte sedimentation rate (ESR).
- C. Decreased megakaryocytes.
- D. Increased WBC.
Correct Answer: A
Rationale: The correct answer is A: Decreased platelet count. In idiopathic thrombocytopenic purpura (ITP), there is a decrease in platelet count due to immune-mediated destruction of platelets. This can lead to bleeding tendencies. Other choices are incorrect because in ITP, there is no significant change in ESR (B), megakaryocytes may be increased or normal (C), and WBC count is usually normal or slightly elevated (D).
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A nurse is caring for a client who is at 22 weeks of gestation and is HIV positive. Which of the following actions should the nurse take?
- A. Administer penicillin G 2.4 million units IM to the client.
- B. Instruct the client to schedule annual pelvic examination.
- C. Tell the client they will start medication for HIV immediately after delivery.
- D. Report the client's condition to the local health Department.
Correct Answer: D
Rationale: The correct answer is D: Report the client's condition to the local health department. This is important to ensure proper monitoring, follow-up, and infection control measures. Reporting is necessary for contact tracing, prevention of transmission, and accessing appropriate support services. Administering penicillin G (A) is not indicated for HIV; the client needs antiretroviral therapy. Scheduling annual pelvic exams (B) is important for general health but not specific to HIV care. Waiting until after delivery to start HIV medication (C) is not recommended as timely treatment is crucial.
A nurse is assessing a newborn following a circumcision. Which of the following findings should the nurse identify as an indication that the newborn is experiencing pain?
- A. Decreased heart rate.
- B. Chin quivering.
- C. Pinpoint pupils.
- D. Slowed respirations.
Correct Answer: B
Rationale: The correct answer is B: Chin quivering. Pain assessment in newborns can be challenging due to their limited ability to communicate. Chin quivering is a common behavioral indicator of pain in newborns. It is a subtle sign of distress and discomfort. Other choices such as decreased heart rate (A), pinpoint pupils (C), and slowed respirations (D) are not reliable indicators of pain in newborns. Decreased heart rate can indicate relaxation, pinpoint pupils are more indicative of opioid use, and slowed respirations might be a sign of sleepiness or relaxation rather than pain.
A nurse is planning care for a client who is to undergo a nonstress test. Which of the following actions should the nurse include in the plan of care?
- A. Maintain the client NPO throughout the procedure.
- B. Place the client in a supine position.
- C. Instruct the client to massage the abdomen to stimulate fetal movement.
- D. Instruct the client to press the provided button each time fetal movement is detected.
Correct Answer: D
Rationale: The correct answer is D: Instruct the client to press the provided button each time fetal movement is detected. This action is essential during a nonstress test to track fetal movement and heart rate patterns. By pressing the button each time fetal movement is felt, the nurse can correlate these movements with any changes in the fetal heart rate, providing valuable information about fetal well-being. Maintaining the client NPO (A) is not necessary for a nonstress test. Placing the client in a supine position (B) can reduce blood flow to the fetus and is not recommended. Instructing the client to massage the abdomen (C) may lead to inaccurate test results by artificially stimulating fetal movements.
A nurse is reviewing the medical record of a newly admitted client who is at 32 weeks of gestation. Which of the following conditions is an indication for fetal assessment using electronic fetal monitoring?
- A. Oligohydramnios.
- B. Hyperemesis gravidarum.
- C. Leukorrhea.
- D. Periodic tingling of the fingers.
Correct Answer: A
Rationale: The correct answer is A: Oligohydramnios. Electronic fetal monitoring is indicated for assessing fetal well-being in pregnancies with conditions that may compromise fetal oxygenation, such as oligohydramnios. Oligohydramnios is a condition where there is an insufficient amount of amniotic fluid around the fetus, which can lead to fetal distress. Electronic fetal monitoring helps track the fetal heart rate and uterine contractions to detect signs of distress. Hyperemesis gravidarum (B), leukorrhea (C), and periodic tingling of the fingers (D) are not indications for fetal monitoring as they do not directly impact fetal well-being.
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 can indicate hyperemesis gravidarum, a severe form of nausea and vomiting during pregnancy that can lead to dehydration and electrolyte imbalances. This finding is concerning and requires immediate medical attention to prevent complications. Reporting this to the provider allows for timely intervention.
Other choices are incorrect:
B: Reports of mood swings are common during pregnancy due to hormonal changes and are not typically a cause for immediate concern.
C: Nosebleeds occurring approximately 3 times per week can be due to increased blood flow during pregnancy and are usually not a significant concern unless severe or persistent.
D: Increased vaginal discharge is a common symptom in early pregnancy due to hormonal changes and increased blood flow to the pelvic area. It is not typically an urgent issue unless accompanied by other symptoms like itching or foul odor.