Nokea
A nurse is caring for a client who has pregestational diabetes mellitus. Which of the following clinical findings should indicate to the nurse that the client has hyperglycemia?
- A. Dizziness
- B. Increased urination
- C. Double vision
- D. Sweating
Correct Answer: B
Rationale: Increased urination (polyuria) is a hallmark of hyperglycemia as the body excretes excess glucose, unlike dizziness, double vision, or sweating (more hypoglycemic symptoms).
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A nurse is caring for a client who is at 32 weeks of gestation and has gestational diabetes mellitus. Which of the following findings should the nurse report to the provider?
- A. The client has a fundal height of 38 cm
- B. The client has a fasting blood glucose of 90 mg/dL
- C. The client reports 12 fetal movements in 1 hr
- D. The client has nonpitting pedal edema
Correct Answer: A
Rationale: A fundal height of 38 cm at 32 weeks suggests macrosomia, a gestational diabetes complication, requiring reporting, unlike normal glucose, fetal movements, or edema.
A nurse is performing an assessment of a newborn's Babinski reflex. Which of the following findings should the nurse expect?
- A. Eversion of the great toe
- B. Flexion of the forearm
- C. The downward curl of the toes
- D. Extension of the leg
Correct Answer: A
Rationale: A positive Babinski reflex in newborns shows dorsiflexion and fanning of toes, unlike forearm flexion, toe curling, or leg extension.
A nurse in a newborn nursery is receiving a change-of-shift report for four newborns. Which of the following newborns should the nurse assess first?
- A. A newborn who has a short frenulum and is having difficulty breastfeeding
- B. A newborn who is 24 hr old and has not had a meconium stool
- C. A newborn who is 10 hr old and has blood-tinged discharge in her diaper
- D. A newborn who is 10 hr old and has new onset tachypnea
Correct Answer: D
Rationale: New onset tachypnea signals potential respiratory distress, requiring urgent assessment, unlike breastfeeding issues, delayed stool, or normal blood-tinged discharge.
A nurse is reviewing the electronic medical record of a postpartum client. The nurse should identify that which of the following factors places the client at risk for an infection?
- A. Midline episiotomy
- B. Meconium-stained fluid
- C. Gestational hypertension
- D. Placenta previa
Correct Answer: B
Rationale: Meconium-stained fluid increases maternal infection risk if it enters the bloodstream, unlike episiotomy (managed risk), hypertension, or previa (other complications).
A nurse is assessing the results of a nonstress test for an antepartum client at 35 weeks of gestation. Which of the following findings should indicate to the nurse the need for further diagnostic testing?
- A. Three fetal movements perceived by the client in a 20 min testing period
- B. No late decelerations in the fetal heart rate noted with three uterine contractions of 60 seconds in duration within a 10-min resting period
- C. An increase in fetal heart rate to 150/min above the baseline of 140/min lasting 10 seconds in response to fetal movement within a 40-min testing period
- D. Irregular contractions of 10 to 20 seconds in duration that are not felt by the client
Correct Answer: A
Rationale: Only three fetal movements in 20 minutes is below the expected activity level, suggesting possible fetal compromise, unlike reassuring heart rate responses or minor contractions.