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 thrombocytopenia purpura (ITP), there is a decrease in platelet count due to immune-mediated destruction of platelets. This can lead to an increased risk of bleeding.
Explanation for other choices:
B: Increased erythrocyte sedimentation rate (ESR) is not typically associated with ITP.
C: Decreased megakaryocytes may be seen in some cases of ITP but is not a consistent finding.
D: Increased WBC is not a characteristic finding in ITP.
Therefore, the most relevant finding in a client with ITP would be a decreased platelet count due to the underlying pathophysiology of the condition.
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A nurse is caring for a client who has preeclampsia and is receiving a continuous infusion of magnesium sulfate IV. Which of the following actions should the nurse take?
- A. Restrict hourly fluid intake to 150 mL/hr.
- B. Have calcium gluconate readily available.
- C. Assess deep tendon reflexes every 6 hr.
- D. Monitor intake and output every 4 hr.
Correct Answer: B
Rationale: The correct answer is B: Have calcium gluconate readily available. Magnesium sulfate can lead to magnesium toxicity, causing respiratory depression and cardiac arrest. Calcium gluconate is the antidote for magnesium toxicity, so having it readily available is crucial for immediate administration if toxicity occurs. Option A is incorrect as fluid intake should not be restricted in preeclampsia. Option C is incorrect as deep tendon reflexes should be assessed more frequently (every 1-2 hours) due to the risk of hypermagnesemia. Option D is incorrect as intake and output should be monitored hourly to detect any changes in renal function.
Which of the following conditions should the nurse identify as being consistent with the adolescent's assessment findings? For each finding click to specify if the assessment findings are consistent with trichomoniasis, gonorrhea, or candidiasis. Each finding may support more than one disease process.
- A. Abdominal pain.
- B. Greenish discharge.
- C. Diabetes.
- D. Pain on urination.
- E. Absence of condom.
Correct Answer: B, D
Rationale: To determine the correct answer, we need to identify which assessment findings are consistent with trichomoniasis, gonorrhea, or candidiasis.
B: Greenish discharge is consistent with both trichomoniasis and gonorrhea due to their characteristic discharge color.
D: Pain on urination is a common symptom of gonorrhea, making it consistent with this condition.
Therefore, the correct answer is , as Greenish discharge and Pain on urination are consistent with gonorrhea. Abdominal pain and Diabetes are not specific to any of the mentioned conditions.
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 is concerning as it could indicate hyperemesis gravidarum, a severe form of morning sickness that can lead to dehydration and malnutrition, posing risks to both the mother and fetus. It requires medical intervention to prevent complications.
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 are common in pregnancy due to increased blood volume and hormonal changes. They are usually not a significant concern unless they are severe or accompanied by other symptoms.
D: Increased vaginal discharge is a normal occurrence in pregnancy due to hormonal changes and increased blood flow to the pelvic area. It is not typically a cause for immediate concern unless it is accompanied by other symptoms like itching, burning, or foul odor.
A nurse is caring for a client who is to receive oxytocin to augment their labor. Which of the following findings contraindicates the initiation of the oxytocin infusion and should be reported to the provider?
- A. Late decelerations.
- B. Moderate variability of the FHR.
- C. Cessation of uterine dilation.
- D. Prolonged active phase of labor.
Correct Answer: A
Rationale: The correct answer is A: Late decelerations. Late decelerations indicate uteroplacental insufficiency, potentially leading to fetal distress. Oxytocin can further stress the fetus by increasing uterine contractions, exacerbating the late decelerations. Late decelerations are a sign of decreased oxygen supply to the fetus, making it unsafe to augment labor with oxytocin. Therefore, this finding should be reported to the provider to ensure the safety of both the client and the fetus.
Incorrect choices:
B: Moderate variability of the FHR is a reassuring sign of fetal well-being, not a contraindication for oxytocin infusion.
C: Cessation of uterine dilation may indicate a stalled labor progress but is not a contraindication for initiating oxytocin.
D: Prolonged active phase of labor may warrant augmentation with oxytocin rather than being a contraindication.
A nurse is observing a new guardian caring for their crying newborn who is bottle feeding. Which of the following actions by the guardian should the nurse recognize as a positive parenting behavior?
- A. Lays the newborn across their lap and gently sways.
- B. Places the newborn in the crib in a prone position.
- C. Offers the newborn a pacifier dipped in formula.
- D. Prepares a bottle of formula mixed with rice cereal.
Correct Answer: A
Rationale: The correct answer is A because laying the newborn across the lap and gently swaying can help soothe the baby by providing comfort and closeness. This position mimics the feeling of being held in the womb and the swaying motion can be calming. Placing the newborn in the crib in a prone position (B) is not recommended due to the risk of sudden infant death syndrome. Offering a pacifier dipped in formula (C) may lead to overfeeding and potential nipple confusion. Preparing a bottle of formula mixed with rice cereal (D) is not recommended for newborns as their digestive systems are not ready for solids.