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A nurse is caring for a client who is 36 weeks gestation and has MRSA. Which of the following isolation precautions should the nurse initiate?
- A. Droplet
- B. Contact
- C. Airborne
- D. Protective environment
Correct Answer: B
Rationale: The correct answer is B: Contact precautions. MRSA is primarily spread through direct contact with an infected person or contaminated surfaces. By implementing contact precautions, the nurse can prevent the transmission of MRSA to other patients or healthcare workers. Droplet precautions (choice A) are used for diseases spread via respiratory droplets, such as influenza. Airborne precautions (choice C) are for diseases transmitted through small particles in the air, like tuberculosis. Protective environment (choice D) is used for immunocompromised patients to protect them from environmental pathogens. In this scenario, contact precautions are the most appropriate choice to prevent the spread of MRSA.
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A nurse is assessing a client during her first prenatal visit the client reports March 20th us her last menstrual.. Use Niagele9s rule to calculate the estimated date of delivery. Use the mmdd format with four numerals and no spaces or punctuation.
- A. 05/11
- B. 5/4
- C. 5/12
- D. 04/27
Correct Answer: A
Rationale: The correct answer is A: 05/11. Using Naegele's rule, add 7 days to the first day of the last menstrual period (March 20), subtract 3 months, and add 1 year. March 20 + 7 days = March 27. Subtracting 3 months gives us December 27. Adding 1 year brings us to December 27 of the following year. However, since we are looking for the estimated date of delivery, we add 7 days to adjust for the 7 days we added at the beginning, which gives us May 4. Therefore, the estimated date of delivery would be May 11. Choice B (5/4) is incorrect because it does not account for the 7-day adjustment. Choice C (5/12) is incorrect as it adds 7 days twice. Choice D (04/27) is incorrect as it doesn't correctly follow Naegele's rule.
A nurse is caring for a client who has gestational diabetes mellitus. Which of the following clinical findings should indicate to the nurse the client has hyperglycemia?
- A. Double vision
- B. Increased urination
- C. Sweating
- D. Dizziness
Correct Answer: B
Rationale: The correct answer is B: Increased urination. Hyperglycemia in gestational diabetes mellitus leads to elevated blood glucose levels, causing the kidneys to work harder to filter and remove excess sugar from the blood. This results in increased urination (polyuria) as the body tries to eliminate the excess glucose through urine. Double vision (A) is more indicative of neurological issues, sweating (C) can be due to various reasons such as anxiety or hormonal changes, and dizziness (D) may be related to blood pressure changes or inner ear problems. Therefore, increased urination is the most specific clinical finding associated with hyperglycemia in gestational diabetes mellitus.
A nurse is caring for a client who is at 30 weeks of gestation. The nurse should plan to immunize the client which of the following vaccinations? Select all the apply
- A. Varicella
- B. human papillomavirus
- C. Diphtheria - acellular pertussis
- D. inactivated influenza
- E. measles, mumps, and rubella
Correct Answer: C,D
Rationale: The correct answers are C (Diphtheria - acellular pertussis) and D (inactivated influenza) for a client at 30 weeks gestation. These vaccines are safe during pregnancy and provide protection to both the mother and the developing fetus. Diphtheria and pertussis can cause severe complications for newborns, so vaccinating the mother during pregnancy helps pass on immunity. Influenza vaccination is recommended to reduce the risk of severe illness in pregnant women and their babies. Choices A, B, and E are contraindicated during pregnancy due to potential harm to the fetus.
A nurse is caring for a client who reports spontaneous rupture. The nurse observed fetal bradycardia in the FHR tracing and notices the umbilical cord is protruding. After calling for assistance and notifying the provider, which of the following should the nurse take next?
- A. Initiate an infusion of IV fluids for the client
- B. Perform vaginal examination by applying upward pressure on the presenting part
- C. Administer oxygen via non rebreather mask at 8L/ min. D. Cover the umbilical cord with sterile saline saturated towel.
- D. Cover the umbilical cord with sterile saline saturated towel.
Correct Answer: D
Rationale: The correct answer is D: Cover the umbilical cord with sterile saline saturated towel. This is the correct next step because it helps prevent compression of the cord, which could lead to fetal compromise. By covering the cord with a sterile saline towel, the nurse can protect it from drying out and maintain a moist environment. This step is crucial in preventing further harm to the fetus.
A: Initiate an infusion of IV fluids for the client - This is not the priority at this moment. The focus should be on managing the umbilical cord prolapse and fetal distress.
B: Perform vaginal examination by applying upward pressure on the presenting part - This action could potentially worsen the situation by further compressing the cord. It is not recommended in this scenario.
C: Administer oxygen via non-rebreather mask at 8L/min - While oxygenation is important for the client and fetus, managing the umbilical cord prolapse takes precedence in this situation.
In summary, covering
A nurse is caring for four enter-partum clients. Which of the following clients should the nurse assess first?
- A. A client who is at 7 weeks of gestation and reports urinary frequency
- B. A client who is at 32 weeks of gestation and reports seeing floating spots
- C. A client who is 38 weeks of gestation and reports leg cramps
- D. A client who is at 20 weeks of gestation and reports periodic numbness in her fingers
Correct Answer: B
Rationale: The correct answer is B. The nurse should assess the client at 32 weeks of gestation reporting seeing floating spots first because it could indicate a serious condition called preeclampsia, characterized by high blood pressure and organ damage. This client's symptom is a sign of visual disturbances, a classic symptom of preeclampsia. Immediate assessment is necessary to prevent complications such as seizures and stroke. The other clients' symptoms, urinary frequency, leg cramps, and periodic numbness in fingers, are common discomforts in pregnancy but do not suggest immediate serious complications like preeclampsia.