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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 is caring for a newborn.
Exhibit1
Vital Signs
8 hr of age:
Temperature: 37.1° C (98.8° F) Axillary
Pulse rate: 132/min
Respiratory rate: 52/min
36 hr of age:
Temperature: 36.1° C (97" F) Axillary
Pulse rate: 160/min
Respiratory rate: 78/min”
For each assessment finding, click to specify if the finding is consistent with hypoglycemia, hyperbilirubinemia, or sepsis.
- A. Ecchymotic caput Succedaneum.
- B. Decreased temperature.
- C. Lethargy.
- D. Poor feeding.
- E. Respiratory distress.
- F. Yellow sclera and oral mucosa.
Correct Answer: B, C, D, E, F
Rationale: The correct answer is . Decreased temperature (B) can indicate hypoglycemia, sepsis, or hypothermia. Lethargy (C) can be a sign of hypoglycemia, sepsis, or other serious conditions. Poor feeding (D) is common in hypoglycemia, sepsis, and other illnesses. Respiratory distress (E) is a red flag for sepsis. Yellow sclera and oral mucosa (F) suggest hyperbilirubinemia. Ecchymotic caput Succedaneum (A) is not typically associated with these conditions.
A nurse is caring for a 1-month-old infant who has manifestations of severe dehydration and a prescription for parenteral fluid therapy. The guardian asks, 'What are the indications that my baby needs an IV?' Which of the following responses should the nurse make?
- A. Your baby needs an IV because she is not producing tears.
- B. Your baby needs an IV because her heart rate is decreased.
- C. Your baby needs an IV because she is breathing slower than normal.
- D. Your baby needs an IV because her fontanels are bulging.
Correct Answer: A
Rationale: The correct answer is A. Infants with severe dehydration may not produce tears due to lack of fluid. This indicates the need for IV fluid therapy to rehydrate the baby. Lack of tears is a sign of significant dehydration in infants.
Option B, decreased heart rate, is not a specific sign of dehydration in infants and not a direct indication for IV fluids. Option C, slow breathing, is also not a direct indication of dehydration, as infants may have varied respiratory rates for other reasons. Option D, bulging fontanels, can be a sign of increased intracranial pressure but is not a direct indication for IV fluids in this context.
A nurse is preparing to administer azithromycin to a client who is at 16 weeks of gestation and has a positive chlamydia culture. The prescription states "Administer azithromycin 1 g orally now." Available are 250 mg tablets. How many tablets should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
- A. 8 tablets
- B. 6 tablets
- C. 4 tablets
- D. 2 tablets
Correct Answer: C
Rationale: The correct answer is C: 4 tablets. Azithromycin 1g is equivalent to 1000mg. Since each tablet is 250mg, the nurse should administer 1000mg/250mg = 4 tablets. This dosage is appropriate for treating chlamydia infection. Choice A is incorrect because 8 tablets would be equivalent to 2000mg, which is double the prescribed dosage. Choice B is incorrect as 6 tablets would be 1500mg, which is higher than the prescribed dosage. Choice D is incorrect as 2 tablets would only be 500mg, which is lower than the prescribed dosage.
A nurse is caring for a client who is in labor and requires augmentation of labor. Which of the following conditions should the nurse recognize as a contraindication to the use of oxytocin?
- A. Post-term with oligohydramnios.
- B. Chorioamnionitis
- C. Shoulder presentation
- D. Diabetes mellitus
Correct Answer: C
Rationale: The correct answer is C: Shoulder presentation. This condition is a contraindication to the use of oxytocin because it can lead to complications such as umbilical cord prolapse, which can be dangerous for both the mother and the baby. Oxytocin can increase the strength and frequency of contractions, potentially worsening the situation.
Choice A: Post-term with oligohydramnios is not a contraindication to the use of oxytocin. It may actually be a reason to consider augmentation of labor.
Choice B: Chorioamnionitis is an infection of the fetal membranes and amniotic fluid, and while it may require treatment, it is not a contraindication to the use of oxytocin.
Choice D: Diabetes mellitus is not a contraindication to the use of oxytocin unless there are specific complications related to diabetes that would make its use risky.
In summary, the correct answer, shoulder presentation,
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.