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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 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 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, meaning the baby is not getting enough oxygen during contractions. Administering oxytocin, which can further stress the baby by increasing contractions, can worsen the situation. Late decelerations are a sign of fetal distress and require immediate intervention.
B: Moderate variability of the FHR is a normal finding and does not contraindicate the initiation of oxytocin.
C: Cessation of uterine dilation would suggest a potential issue with labor progress but does not directly contraindicate oxytocin.
D: Prolonged active phase of labor may warrant oxytocin to augment contractions but is not a contraindication itself.
A nurse is planning care for a client who is in labor and is to have an amniotomy. Which of the following assessments should the nurse identify as the priority?
- A. O2 saturation.
- B. Temperature.
- C. Blood pressure.
- D. Urinary output.
Correct Answer: B
Rationale: The correct answer is B: Temperature. During an amniotomy, there is a risk of infection due to the introduction of bacteria into the amniotic fluid. Monitoring the client's temperature is crucial as an elevated temperature could indicate infection, which can be life-threatening for both the mother and the fetus. O2 saturation (A), blood pressure (C), and urinary output (D) are important assessments but not the priority in this situation. O2 saturation is typically monitored continuously during labor, blood pressure can fluctuate during labor but is not directly impacted by amniotomy, and urinary output is important for assessing hydration status but does not take precedence over monitoring for infection.
Which of the following conditions is the client most likely developing?
- A. Pelvic inflammatory.
- B. Ectopic pregnancy.
- C. Pyclonephritis.
- D. C-reactive protein.
- E. Beta hCG.
- F. Urinalysis.
Correct Answer: A
Rationale: [1, 0, 0, 0, 0, 0]
The correct answer is A: Pelvic inflammatory. Pelvic inflammatory disease is an infection of the female reproductive organs, often caused by sexually transmitted infections. It presents with symptoms like pelvic pain, abnormal vaginal discharge, and fever. Ectopic pregnancy (B) is the implantation of a fertilized egg outside the uterus and presents with abdominal pain and vaginal bleeding. Pyelonephritis (C) is a kidney infection, typically causing fever and flank pain. C-reactive protein (D) is a marker for inflammation and infection, not a specific condition. Beta hCG (E) is a hormone produced in pregnancy. Urinalysis (F) is a test to analyze urine composition, not a condition.
A nurse is assessing a client who is in active labor. Which of the following findings should the nurse report to the provider?
- A. Contractions lasting 80 seconds.
- B. Early decelerations in the PHR.
- C. Temperature 37.4° C (99 3* F).
- D. PHR baseline 170/min.
Correct Answer: D
Rationale: The correct answer is D: PHR baseline 170/min. A baseline fetal heart rate (FHR) of 170/min is considered tachycardia in labor, which may indicate fetal distress. The nurse should report this finding to the provider promptly for further evaluation and intervention. Contractions lasting 80 seconds (choice A) are within the normal range. Early decelerations (choice B) are typically benign and do not require immediate intervention. A temperature of 37.4° C (choice C) is slightly elevated but not a critical finding in active labor. Therefore, choice D is the most concerning and requires immediate attention.
A nurse is assessing a newborn who is 16 hr old. Which of the following findings should the nurse report to the provider?
- A. Substernal retractions.
- B. Acrocyanosis.
- C. Overlapping suture lines.
- D. Head circumference 33 cm (13 in).
Correct Answer: A
Rationale: The correct answer is A: Substernal retractions. Substernal retractions indicate respiratory distress in a newborn, which can be a serious issue requiring immediate medical attention. Acrocyanosis (choice B) is a common finding in newborns and is not concerning. Overlapping suture lines (choice C) can be normal in newborns and typically resolve on their own. A head circumference of 33 cm (13 in) (choice D) is within the normal range for a newborn.