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A nurse is caring for a client who is at 10 weeks of gestation. Which of the following findings should the nurse report to the provider?
- A. Frequent vomiting with weight loss of 3 lb in 1 week
- B. Reports of mood swings
- C. Nosebleeds occurring approximately 3 times per week
- D. Increased vaginal discharge
Correct Answer: A
Rationale: The correct answer is A. Frequent vomiting with weight loss of 3 lb in 1 week is concerning as it could indicate hyperemesis gravidarum, a severe form of morning sickness that can lead to dehydration and malnutrition, posing risks to both the mother and fetus. It requires medical intervention to prevent complications.
B: Reports of mood swings are common during pregnancy due to hormonal changes and are not typically a cause for immediate concern.
C: Nosebleeds occurring approximately 3 times per week are common in pregnancy due to increased blood volume and hormonal changes. They are usually not a significant concern unless they are severe or accompanied by other symptoms.
D: Increased vaginal discharge is a normal occurrence in pregnancy due to hormonal changes and increased blood flow to the pelvic area. It is not typically a cause for immediate concern unless it is accompanied by other symptoms like itching, burning, or foul odor.
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A nurse in a clinic is caring for a 16-year-old adolescent. Which of the following findings should the nurse report to the provider? (Select all that apply.)
- A. Abdominal assessment
- B. Vaginal discharge
- C. Heart rate
- D. Temperature
- E. Dyspareunia
- F. Condom usage
Correct Answer: A,B,D,E,F
Rationale: The correct answers to report to the provider are A, B, D, E, and F. A: Abdominal assessment is crucial to identify any potential underlying issues. B: Vaginal discharge in an adolescent may indicate infection or hormonal imbalance. D: Temperature abnormalities could signal infection. E: Dyspareunia (pain during intercourse) may indicate reproductive health concerns. F: Condom usage is important for safe sex practices. Choices C and G are not specifically related to the adolescent's care needs and do not require immediate reporting.
A nurse is caring for a client who is to receive oxytocin to augment their labor. Which of the following findings contraindicates the initiation of the oxytocin infusion and should be reported to the provider?
- A. Late decelerations.
- B. Moderate variability of the FHR.
- C. Cessation of uterine dilation.
- D. Prolonged active phase of labor.
Correct Answer: A
Rationale: The correct answer is A: Late decelerations. Late decelerations indicate uteroplacental insufficiency, potentially leading to fetal distress. Oxytocin can further stress the fetus by increasing uterine contractions, exacerbating the late decelerations. Late decelerations are a sign of decreased oxygen supply to the fetus, making it unsafe to augment labor with oxytocin. Therefore, this finding should be reported to the provider to ensure the safety of both the client and the fetus.
Incorrect choices:
B: Moderate variability of the FHR is a reassuring sign of fetal well-being, not a contraindication for oxytocin infusion.
C: Cessation of uterine dilation may indicate a stalled labor progress but is not a contraindication for initiating oxytocin.
D: Prolonged active phase of labor may warrant augmentation with oxytocin rather than being a contraindication.
A nurse is caring for a newborn who is 70 hr old. Exhibit 1
Medical History
Newborn delivered by repeat cesarean birth at 40 weeks of gestation.
Birth weight 3,515 g (7 lb 12 oz)
Apgar scores 8 at 1 min and 9 at 5 min
Maternal history of methadone use during pregnancy.
Exhibit 2
Vital Signs
0700:
Heart rate 156/min
Respiratory rate 58/min
Temperature 37.2° C (98.9° F)
Oxygen saturation 98% on room air
1100:
Heart rate 160/min
Respiratory rate 60/min
Temperature 37.3° C (99.2° F)
Oxygen saturation 96% on room air
Exhibit 3
Physical Examination
1100:
Newborn is inconsolable with a high-pitched cry. Newborn sucks vigorously on pacifier but
breastfeeds poorly. Respirations unlabored. Lungs sound clear on auscultation. Increased muscle
tone with moderate to severe tremors when disturbed. Hyperactive Moro reflex noted. Several
loose stools today.
Exhibit 4
Diagnostic Results
Maternal urine toxicology screen positive for opiates (negative)
Newborn urine toxicology screen positive for opiates (negative)
Which of the following findings should the nurse report to the provider? Select all that apply.
- A. Respiratory findings
- B. Oxygen saturation
- C. Central nervous system findings
- D. Gastrointestinal findings
Correct Answer: C,D
Rationale: The nurse should report central nervous system (CNS) and gastrointestinal (GI) findings to the provider as they can indicate potential serious issues. CNS findings like altered mental status or neurological deficits may signal neurological problems. GI findings such as abdominal pain or bleeding may indicate gastrointestinal issues that require immediate attention. Respiratory findings (choice A) and oxygen saturation (choice B) are important but may not always require immediate reporting unless they are significantly abnormal. The other choices are not directly related to urgent medical concerns. Reporting CNS and GI findings ensures prompt evaluation and appropriate intervention.
A nurse is reviewing the provider's prescription in the adolescent's medical chart
Exhibit 1
History and Physical, Adolescent is sexually active with two current partners.
IUD in place, Reports not using condoms during sexual activity.
History of type 1 diabetes mellitus
Which of the following indicates whether the adolescent understands the teaching on requires further education?
- A. I should continue taking all my medications even if I don't show any symptoms.
- B. If I continue to get this type of infection, it can affect my ability to have kids in the future.
- C. I should go to the emergency department if my urine turns dark.
- D. As long as I keep my IUD, I don't need to use condoms.
- E. I'm more likely to get a sunburn while taking these medications.
Correct Answer: D
Rationale: Step-by-step rationale for why answer D is correct:
1. Choice D states, "As long as I keep my IUD, I don't need to use condoms." This statement indicates a misunderstanding as IUDs do not protect against sexually transmitted infections .
2. This statement shows a lack of understanding regarding the importance of using condoms to prevent STIs.
3. Therefore, selecting Choice D indicates that further education is required to clarify the misconception about the role of IUDs in STI prevention.
Summary:
- Choice A is correct as it indicates a misunderstanding about the necessity of taking medications regardless of symptoms.
- Choice B is correct as it states a potential consequence of untreated infections, showing understanding.
- Choice C is correct as it highlights a symptom that warrants immediate medical attention.
- Choice E is incorrect as it does not pertain to the understanding of contraception and STI prevention.
- Choices F and G are not applicable and can be disregarded.
A nurse is transporting a newborn back to the parent's room following a procedure. Which of the following actions should the nurse take prior to leaving the newborn with their parent?
- A. Ensure that the parent's identification band number matches the newborn's identification band number.
- B. Ask the parent to verify their name and date of birth.
- C. Check the newborn's security tag number to ensure it matches the newborn's medical record.
- D. Match the newborn's date and time of birth to the information in the parent's medical record.
Correct Answer: A
Rationale: The correct answer is A: Ensure that the parent's identification band number matches the newborn's identification band number. This is crucial for proper identification and prevention of mix-ups. Matching the identification bands ensures that the newborn is going to the correct parent, enhancing safety.
Choice B is incorrect because asking the parent to verify their own information does not confirm the identification of the newborn. Choice C is incorrect as it focuses on the security tag number, which may not be as reliable as the identification bands. Choice D is incorrect as matching the date and time of birth to the parent's medical record does not provide direct confirmation of the parent-newborn match.