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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 ITP, there is a decrease in the number of platelets, leading to an increased risk of bleeding. Platelets are essential for blood clotting, so a decreased count can result in easy bruising, petechiae, and prolonged bleeding. The other choices are incorrect because in ITP, there is no significant increase in ESR, decrease in megakaryocytes (which are platelet precursors), or increase in WBC count. By understanding the pathophysiology of ITP and its effects on platelets, we can confidently select choice A as the expected finding in this scenario.
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Which of the following actions should the nurse plan to implement? For each potential nursing action, click to specify if the intervention is indicated or contraindicated for the newborn.
- A. Educate the parents to begin range of motion exercises on the affected arm after 1 week.
- B. Assess for grasp reflex in the affected extremity.
- C. Immobilize the arm across the abdomen by pinning the newborn's sleeve to their shirt.
- D. Instruct parents to limit physical handling for 2 weeks.
Correct Answer:
Rationale: Correct Answer:
Rationale:
- Educate the parents to begin range of motion exercises on the affected arm after 1 week is indicated as it promotes joint mobility.
- Assess for grasp reflex in the affected extremity is contraindicated as it can cause discomfort and potential harm.
- Immobilizing the arm across the abdomen is contraindicated as it can restrict circulation and hinder development.
- Instructing parents to limit physical handling for 2 weeks is indicated to prevent excessive stress on the affected arm.
A nurse is providing teaching about increasing dietary fiber to an antepartum client who reports constipation. Which of the following food selections has the highest fiber content per cup?
- A. Oatmeal
- B. Cabbage
- C. Asparagus
- D. Lentils
Correct Answer: D
Rationale: The correct answer is D, Lentils. Lentils have the highest fiber content per cup compared to the other options. Lentils provide approximately 15.6 grams of fiber per cup, making them an excellent choice to alleviate constipation. Oatmeal, while a good source of fiber, typically contains around 4 grams per cup. Cabbage and asparagus have lower fiber content compared to lentils. In summary, lentils are the best choice for increasing dietary fiber due to their high fiber content per cup, which can effectively help relieve constipation in the antepartum client.
A nurse is assessing a late preterm newborn. Which of the following manifestations is an indication of hypoglycemia?
- A. Hypertonia
- B. Increased feeding
- C. Hyperthermia
- D. Respiratory distress
Correct Answer: D
Rationale: Correct Answer: D - Respiratory distress
Rationale: Hypoglycemia in a late preterm newborn can lead to respiratory distress due to inadequate glucose supply to the brain, causing dysfunction in respiratory centers. This can manifest as tachypnea, grunting, nasal flaring, and retractions. Hypertonia, increased feeding, and hyperthermia are not specific signs of hypoglycemia in newborns.
Summary:
A: Hypertonia is not a typical manifestation of hypoglycemia in newborns.
B: Increased feeding is more likely to be seen in newborns with hunger cues, not necessarily indicative of hypoglycemia.
C: Hyperthermia is not a common sign of hypoglycemia in newborns.
A nurse is providing prenatal teaching to a client who practices a vegan diet and is trying to increase intake of vitamin B12. Which of the following foods should the nurse recommend?
- A. Fortified soy milk
- B. Raw carrots
- C. Fresh citrus fruits
- D. Brown rice
Correct Answer: A
Rationale: The correct answer is A: Fortified soy milk. Vitamin B12 is mainly found in animal products, making it challenging for vegans to obtain sufficient amounts. Fortified soy milk is a great source of vitamin B12 for vegans. Raw carrots (B), fresh citrus fruits (C), and brown rice (D) do not contain significant amounts of vitamin B12. It is important for the nurse to recommend a food source that is rich in vitamin B12 to help the client meet their nutritional needs.
A nurse is providing teaching to a client who is at 35 weeks of gestation and has a prescription for an amniocentesis. Which of the following client statements indicates an understanding of the teaching?
- A. I should empty my bladder before the procedure.
- B. I will be lying on my side during the procedure.
- C. I will be asleep during the procedure.
- D. I should start fasting 24 hours before the procedure.
Correct Answer: A
Rationale: The correct answer is A: "I should empty my bladder before the procedure." This statement indicates understanding because a full bladder can obstruct visualization during the amniocentesis. Choice B is incorrect because the client should be lying flat on their back during the procedure. Choice C is incorrect as local anesthesia is typically used, and the client is awake. Choice D is incorrect as fasting is not required for an amniocentesis.