Nokea
A nurse is caring for a child who has hemophilia. The nurse should expect abnormal results in which of the following diagnostic tests?
- A. Fibrinogen
- B. Hemoglobin level
- C. Prothrombin time (PT)
- D. Partial thromboplastin time (PTT)
Correct Answer: D
Rationale: The correct answer is D: Partial thromboplastin time (PTT). In hemophilia, there is a deficiency in specific clotting factors, leading to prolonged PTT due to impaired intrinsic pathway function. A: Fibrinogen level is normal in hemophilia as it is not affected by clotting factor deficiencies. B: Hemoglobin level is unrelated to hemophilia and reflects oxygen-carrying capacity of blood. C: Prothrombin time (PT) evaluates the extrinsic pathway, which is typically normal in hemophilia. Therefore, the abnormal result is in PTT, making it the correct choice.
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The nurse performs Leopold's maneuvers for a client admitted in labor. Which is the main goal of Leopold's maneuvers?
- A. To determine whether the client's cervix has dilated
- B. To assess the frequency and intensity of the contractions
- C. To assess whether membranes have been ruptured
- D. To determine the presentation and position of the fetus
Correct Answer: D
Rationale: The correct answer is D: To determine the presentation and position of the fetus. Leopold's maneuvers involve a series of palpations to assess the fetal lie, presentation, position, and engagement. By performing these maneuvers, the nurse can determine the position of the fetus in relation to the mother's pelvis and whether the baby is in a vertex or breech presentation. This information is crucial in planning for a safe delivery and identifying any potential complications.
Other choices are incorrect because:
A: Leopold's maneuvers do not directly assess cervical dilation.
B: Contractions are typically monitored separately using a tocodynamometer.
C: Checking for ruptured membranes is done through a separate assessment.
In summary, Leopold's maneuvers primarily focus on assessing the presentation and position of the fetus to guide the delivery process effectively.
A client in preterm labor is admitted to the hospital. Which classification of drugs should the nurse anticipate administering?
- A. Tocolytics
- B. Anticonvulsants
- C. Glucocorticoids
- D. Anti-infective
Correct Answer: A
Rationale: The correct answer is A: Tocolytics. Tocolytics are drugs used to inhibit uterine contractions and delay preterm labor. They help prevent premature birth and allow time for other interventions. Anticonvulsants (B) are used to treat seizures, not preterm labor. Glucocorticoids (C) are given to enhance fetal lung maturity in preterm labor, but do not inhibit contractions. Anti-infectives (D) are used to treat infections, not preterm labor. Therefore, tocolytics are the most appropriate choice in this scenario.
A client is admitted to the hospital for induction of labor. Which are the main indications for labor induction?
- A. Placenta previa and twins
- B. Pregnancy-induced hypertension and postterm fetus
- C. Breech position and prematurity
- D. Cephalopelvic disproportion and fetal distress
Correct Answer: B
Rationale: The correct answer is B: Pregnancy-induced hypertension and postterm fetus. Labor induction is commonly indicated in cases of pregnancy-induced hypertension to prevent complications such as preeclampsia. Postterm fetus is another common indication to prevent risks associated with a prolonged pregnancy, such as stillbirth. Placenta previa, twins, breech position, prematurity, cephalopelvic disproportion, and fetal distress are not typically primary indications for labor induction. Placenta previa may require a cesarean section, twins may be delivered vaginally or by C-section, breech position may require external cephalic version or C-section, prematurity may necessitate medical management, cephalopelvic disproportion may require a C-section, and fetal distress may necessitate immediate delivery but not necessarily labor induction.
A breastfeeding mother complains of cramping. Which is the main cause of the client's afterpains?
- A. Infection of the suture line
- B. Constipation and bloating
- C. Contractions of the uterus
- D. Trauma during delivery
Correct Answer: C
Rationale: The correct answer is C: Contractions of the uterus. After giving birth, the uterus continues to contract to reduce in size, which can cause cramping or afterpains. This is a normal process known as involution. Infection of the suture line (A) would present with other symptoms like redness, swelling, and warmth. Constipation and bloating (B) may cause discomfort but are not directly related to afterpains. Trauma during delivery (D) could lead to pain but is not the main cause of afterpains in a breastfeeding mother.
Which assessment finding suggests thrombophlebitis in a postpartum client?
- A. These signs and symptoms are indications of pulmonary embolism.
- B. These signs and symptoms do not relate to thrombophlebitis. Dyspnea, tachypnea, and apprehension
- C. Chills, hypotension, and abdominal tenderness
- D. Positive Homan's sign, calf warmth, and pain
Correct Answer: D
Rationale: The correct answer is D because a positive Homan's sign, calf warmth, and pain are classic signs of thrombophlebitis in a postpartum client. A positive Homan's sign indicates pain in the calf upon dorsiflexion of the foot, which can indicate a blood clot in the leg veins. Calf warmth and pain are also indicative of a possible deep vein thrombosis.
Choices A and B are incorrect because they relate to pulmonary embolism, not thrombophlebitis. Choice C describes signs of sepsis or intra-abdominal pathology, not specifically thrombophlebitis.
In summary, the key indicators of thrombophlebitis in a postpartum client are a positive Homan's sign, calf warmth, and pain, making choice D the correct answer.