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A nurse is caring for a client who has a suspected ectopic pregnancy at 8 weeks of gestation. Which of the following manifestations should the nurse expect to identify as consistent with the diagnosis?
- A. Large amount of vaginal bleeding
- B. Uterine enlargement greater than expected for gestational age
- C. Severe nausea and vomiting
- D. Unilateral, cramp-like abdominal pain
Correct Answer: D
Rationale: The correct answer is D. Unilateral, cramp-like abdominal pain is a classic symptom of an ectopic pregnancy. This pain occurs due to the fallopian tube stretching or rupturing as the embryo grows. This is different from a normal intrauterine pregnancy, where the pain would be central or bilateral.
A: Large amount of vaginal bleeding is not a typical symptom of an ectopic pregnancy.
B: Uterine enlargement greater than expected for gestational age would be seen in a normal intrauterine pregnancy, not an ectopic pregnancy.
C: Severe nausea and vomiting are common symptoms of early pregnancy but are not specific to ectopic pregnancy.
In summary, the key to identifying an ectopic pregnancy is recognizing the combination of abdominal pain and the location of the pain.
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A nurse in a clinic is caring for a client who is 3 weeks postpartum following the birth of a healthy newborn. The client reports feeling “down” and sad, having no energy, and wanting to cry. Which of the following is a priority action by the nurse?
- A. Ask the client if she has considered harming her newborn.
- B. Anticipate a prescription by the provider for an antidepressant.
- C. Reinforce postpartum and newborn care discharge teaching.
- D. Assist the family to identify proper use of positive coping skills in family crises.
Correct Answer: A
Rationale: The correct answer is A. The nurse should ask the client if she has considered harming her newborn as she is experiencing symptoms of postpartum depression. This is a critical step to assess the client's safety and the baby's well-being. Other choices are incorrect as B assumes the need for medication without further assessment, C focuses on teaching rather than immediate safety concerns, and D does not address the client's mental health state. By asking about harming the newborn, the nurse can assess the severity of the client's condition and provide appropriate interventions.
A nurse is assessing a newborn who has developmental dysplasia of the hip (DDH). Which of the following findings should the nurse expect?
- A. Inwardly turned foot on the affected side
- B. Absent plantar reflexes
- C. Lengthened thigh on the affected side
- D. Asymmetric thigh folds
Correct Answer: D
Rationale: The correct answer is D: Asymmetric thigh folds. In DDH, there is an abnormal formation of the hip joint which can lead to dislocation. Asymmetric thigh folds result from the shortened thigh muscles on the affected side due to the dislocation. This finding is indicative of DDH as it reflects the displacement of the femoral head. The other choices are incorrect because an inwardly turned foot (A) is associated with clubfoot, absent plantar reflexes (B) may indicate neurological issues, and a lengthened thigh (C) is not a typical finding in DDH.
A nurse is caring for a client who is postpartum. The client tells the nurse that the newborn’s maternal grandmother was born deaf and asks how to tell if her newborn hears well. Which of the following statements should the nurse make?
- A. “There is no need to worry about that. Most forms of hearing loss are not inherited.”
- B. “We do routine hearing screenings on newborns. You’ll know the results before you leave the hospital.”
- C. “The best way to determine if your baby can hear is to clap your hands loudly and see if she startles.”
- D. “Look at how she looks at you when you speak. That’s a good sign.”
Correct Answer: B
Rationale: Rationale: Choice B is correct because routine hearing screenings for newborns are a standard practice to assess hearing ability. This screening is important for early detection and intervention if hearing loss is present. The other choices are incorrect because: A dismisses the client's concerns and provides inaccurate information, C is not a reliable method to assess hearing, and D, while somewhat accurate, does not provide a definitive assessment like a hearing screening would.
A nurse is caring for a client who is at 40 weeks of gestation and is in labor. The client’s ultrasound examination indicates that the fetus is small for gestational age (SGA). Which of the following interventions should the nurse include in the plan of care after birth?
- A. Observe for meconium in respiratory secretions.
- B. Monitor for hyperthermia.
- C. Identify manifestations of anemia.
- D. Monitor for hyperglycemia.
Correct Answer: A
Rationale: The correct answer is A: Observe for meconium in respiratory secretions. This is important because infants who are small for gestational age (SGA) are at increased risk for meconium aspiration syndrome due to their underdeveloped lungs. Meconium in respiratory secretions can lead to respiratory distress and requires immediate intervention.
Choice B, monitoring for hyperthermia, is incorrect as it is not specifically related to SGA infants. Choice C, identifying manifestations of anemia, is also incorrect as SGA infants may have normal hematologic parameters. Choice D, monitoring for hyperglycemia, is not directly associated with SGA infants and is more relevant to infants of diabetic mothers.
A nurse is caring for several clients. The nurse should recognize that it is safe to administer tocolytic therapy to which of the following clients?
- A. A client who is experiencing preterm labor at 26 weeks of gestation.
- B. A client who is experiencing Braxton-Hicks contractions at 36 weeks of gestation.
- C. A client who has a post-term pregnancy at 42 weeks of gestation.
- D. A client who is experiencing fetal death at 32 weeks of gestation.
Correct Answer: A
Rationale: The correct answer is A: A client who is experiencing preterm labor at 26 weeks of gestation. Tocolytic therapy is used to inhibit uterine contractions and delay preterm labor. Administering tocolytic therapy to a client experiencing preterm labor at 26 weeks helps prevent premature birth and its associated complications. Choices B, C, and D are incorrect because Braxton-Hicks contractions at 36 weeks, post-term pregnancy at 42 weeks, and fetal death at 32 weeks do not warrant tocolytic therapy as they are not indicative of preterm labor.