Nokea
A nurse is caring for a client following an amniocentesis at 18 weeks of gestation. Which of the following findings should the nurse report to the provider as a potential complication?
- A. Increased fetal movement
- B. Leakage of fluid from the vagina
- C. Upper abdominal discomfort
- D. Urinary frequency
Correct Answer: B
Rationale: Correct Answer: B - Leakage of fluid from the vagina
Rationale: Following an amniocentesis at 18 weeks of gestation, leakage of fluid from the vagina could indicate a potential complication such as premature rupture of membranes. This complication could lead to preterm labor and pose a risk to both the mother and the fetus.
Summary of Other Choices:
A: Increased fetal movement - Normal fetal movement is expected following an amniocentesis and does not necessarily indicate a complication.
C: Upper abdominal discomfort - Common after an amniocentesis due to the needle insertion but usually resolves without major issues.
D: Urinary frequency - Not directly related to complications following an amniocentesis at 18 weeks gestation.
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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: Sure, here is the detailed explanation:
- Trichomoniasis: Trichomoniasis typically presents with greenish discharge but not pain on urination.
- Gonorrhea: Gonorrhea can cause both greenish discharge and pain on urination.
- Candidiasis: Candidiasis does not typically present with greenish discharge or pain on urination.
Therefore, based on the assessment findings provided:
- Abdominal pain: Not specific to any of the given conditions.
- Greenish discharge: Consistent with both gonorrhea and trichomoniasis.
- Diabetes: Not directly related to the symptoms provided.
- Pain on urination: Consistent with gonorrhea.
- Absence of condom: Not relevant to the symptoms provided.
The correct answer is B, D as greenish discharge and pain on urination are consistent with both gonorrhea and trichomoniasis, making them the most likely conditions based on the assessment findings.
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 as it helps to monitor the baby's heart rate in response to its movements, providing crucial information about fetal well-being. Pressing the button allows the nurse to correlate fetal movements with changes in the heart rate, helping to assess the baby's overall health and response to stimuli. Maintaining the client NPO (A) is not necessary for a nonstress test. Placing the client in a supine position (B) can decrease blood flow to the baby and is not recommended. Instructing the client to massage the abdomen (C) may artificially stimulate fetal movements, affecting the accuracy of the test results.
A nurse is assessing a newborn who has neonatal abstinence syndrome. Which of the following findings should the nurse expect?
- A. Diminished deep tendon reflexes
- B. Excessive crying
- C. Decreased muscle tone
- D. Absent Moro reflex
Correct Answer: B
Rationale: The correct answer is B: Excessive crying. Neonatal abstinence syndrome is characterized by withdrawal symptoms in newborns due to exposure to drugs in utero. Excessive crying is a common manifestation of this syndrome as the newborn experiences discomfort and agitation. Diminished deep tendon reflexes (A), decreased muscle tone (C), and absent Moro reflex (D) are not typically associated with neonatal abstinence syndrome. These findings may be seen in other conditions, but not specifically in newborns with this syndrome.
A nurse is teaching about car seat safety to the parents of a newborn who was delivered at 38 weeks of gestation. Which of the following statements by a parent indicates an understanding of the teaching?
- A. I can use a sleep sack to keep my baby warm in the car seat.'
- B. My baby will need a car seat challenge test before discharge.'
- C. The car seat should be positioned in the car at a 45-degree angle.'
- D. When my baby is 1 year old, I can turn their car seat facing forward.'
Correct Answer: C
Rationale: The correct answer is C: The car seat should be positioned in the car at a 45-degree angle. This statement demonstrates understanding because newborns who were born at 38 weeks of gestation may have poor muscle tone and need their car seat reclined at a 45-degree angle to keep their airway open. This position helps prevent the baby's head from falling forward and potentially obstructing their breathing.
Choice A is incorrect because using a sleep sack in a car seat can interfere with the proper fit and function of the harness system. Choice B is incorrect because a car seat challenge test is typically done for preterm infants to assess their ability to sit safely in a car seat, not for full-term newborns. Choice D is incorrect because current guidelines recommend keeping infants in a rear-facing car seat until at least 2 years of age, not turning it forward-facing at 1 year old.
A nurse is caring for an infant who has signs of neonatal abstinence syndrome. Which of the following actions should the nurse take?
- A. Monitor blood glucose level every hr.
- B. Place the infant on his back with legs extended.
- C. Initiate seizure precautions.
- D. Provide a stimulating environment.
Correct Answer: C
Rationale: Correct Answer: C - Initiate seizure precautions.
Rationale: Infants with neonatal abstinence syndrome are at risk for seizures due to drug withdrawal. Initiating seizure precautions involves creating a safe environment to prevent injury during a seizure. This includes padding the crib, ensuring a clear space around the infant, and having emergency medications available. Monitoring blood glucose levels every hour (A) is not directly related to neonatal abstinence syndrome. Placing the infant on his back with legs extended (B) is a basic positioning technique and does not address the specific needs of a baby with neonatal abstinence syndrome. Providing a stimulating environment (D) is contraindicated as it can exacerbate symptoms of withdrawal in the infant.