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A nurse is caring for a client who has an NG tube set to low intermittent suction. The nurse irrigates the NG tube twice with 30 mL of normal saline solution during his shift. At the end of the shift, the NG canister contains 475 mL. What amount of NG drainage should the nurse record?
- A. 415 mL
- B. 475 mL
- C. 445 mL
- D. 430 mL
Correct Answer: A
Rationale: NG drainage = canister fluid (475 mL) minus irrigation (2 x 30 mL = 60 mL) = 415 mL. Recording irrigation fluid as drainage would inflate the output inaccurately.
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A pregnant woman undergoes a triple/quadruple screen at 16 to 18 weeks' gestation. What would the nurse suspect if the woman's alpha-fetoprotein (AFP) level is decreased?
- A. Sickle-cell anemia
- B. Cardiac defects
- C. Down syndrome
- D. Respiratory disorders
Correct Answer: C
Rationale: Low AFP suggests Down syndrome, often with altered hCG and estriol. Sickle-cell anemia uses other tests, cardiac defects may raise AFP, and respiratory issues don't typically affect AFP levels.
A nurse is planning a presentation about HIV for a church-based group. Which of the following information about HIV transmission should the nurse include?
- A. It is primarily transmitted through mosquitoes.
- B. It is primarily transmitted through accidental puncture wounds.
- C. It is primarily transmitted through sexual contact.
- D. It is primarily transmitted through respiratory droplets.
Correct Answer: C
Rationale: HIV is primarily transmitted through sexual contact involving infected fluids like semen or vaginal secretions. Mosquitoes, respiratory droplets, and puncture wounds (rare) don't commonly spread HIV.
A pregnant woman undergoes a triple/quadruple screen at 16 to 18 weeks' gestation. What would the nurse suspect if the woman's alpha-fetoprotein (AFP) level is decreased?
- A. Sickle-cell anemia
- B. Cardiac defects
- C. Down syndrome
- D. Respiratory disorders
Correct Answer: C
Rationale: Decreased AFP, with altered hCG and estriol, suggests Down syndrome (trisomy 21). Sickle-cell anemia, cardiac defects, and respiratory disorders don't typically lower AFP; cardiac defects may raise it.
A client's last menstrual period was April 11. Using Nägele's rule, her estimated date of birth (EDB) would be:
- A. 18-Feb
- B. 18-Jan
- C. 8-Jan
- D. 28-Dec
Correct Answer: B
Rationale: Nägele's rule: add 1 year, subtract 3 months, add 7 days. April 11, 2023 + 1 year = April 11, 2024; minus 3 months = January 11, 2024; plus 7 days = January 18, 2024. Other options misapply the rule.
A nurse is teaching a pregnant client in her first trimester about discomforts that she may experience. The nurse determines that the teaching was successful when the woman identifies which discomforts as common during the first trimester? Select all that apply.
- A. Breast tenderness
- B. Urinary frequency
- C. Backache
- D. Cravings
- E. Leg cramps
Correct Answer: A,B,D
Rationale: First trimester discomforts include breast tenderness (hormonal growth), urinary frequency (bladder pressure), and cravings (taste changes). Backache and leg cramps typically occur later due to weight and nerve pressure.