Nokea
A nurse is caring for a client who is at 38 weeks of gestation and is experiencing continuous abdominal pain and vaginal bleeding. The client has a history of cocaine use. The nurse should identify that the client is likely experiencing which of the following complications?
- A. Abruptio placentae
- B. Hydatidiform mole
- C. Preterm labor
- D. Placenta previa
Correct Answer: A
Rationale: Continuous abdominal pain and vaginal bleeding in a client with a history of cocaine use suggest abruptio placentae, where the placenta detaches from the uterus prematurely, posing serious risks to both mother and fetus.
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A laboring client's membranes have just ruptured. What is the nurse's next action?
- A. Assess fetal heart rate pattern
- B. Monitor uterine contractions
- C. Administer oxygen
- D. Prepare for delivery
Correct Answer: A
Rationale: When a client's membranes rupture, there is a risk that the umbilical cord could become compressed, affecting blood flow to the fetus. The nurse's priority action is to assess the fetal heart rate to ensure that the fetus is not in distress.
A nurse is caring for a newborn diagnosed with necrotizing enterocolitis (NEC). Which of the following interventions should the nurse expect to implement?
- A. Administer oral feedings
- B. Measure abdominal girth
- C. Position the newborn prone
- D. Apply warm compresses to the abdomen
Correct Answer: B
Rationale: Measuring abdominal girth is important in monitoring for signs of abdominal distension, which is a key indicator of worsening necrotizing enterocolitis (NEC). Other interventions include withholding oral feedings and providing IV fluids or nutrition.
A nurse is caring for a client who is 36 weeks pregnant and reports leaking fluid. Which of the following tests should the nurse use to confirm that the client¢â‚¬â„¢s membranes have ruptured?
- A. Nonstress test
- B. Biophysical profile
- C. Fern test
- D. Amniocentesis
Correct Answer: C
Rationale: The fern test is used to confirm rupture of membranes. A sample of vaginal fluid is examined under a microscope, and the presence of a fern-like pattern indicates the presence of amniotic fluid.
A nurse is assessing a newborn and notes that the infant has yellow-tinged skin. Which of the following is the priority nursing action?
- A. Assess the infant's bilirubin levels
- B. Initiate phototherapy
- C. Monitor the infant's temperature
- D. Encourage breastfeeding
Correct Answer: A
Rationale: Yellow-tinged skin (jaundice) in a newborn can indicate hyperbilirubinemia. The priority action is to assess the infant's bilirubin levels to determine the severity of the jaundice and the need for further interventions, such as phototherapy.
A nurse is conducting an infertility assessment for a newly admitted client. Which of the following factors should the nurse identify as affecting the client's fertility?
- A. Premature ovarian failure
- B. Renal calculi
- C. Dysmenorrhea
- D. Recurrent urinary tract infection
Correct Answer: A
Rationale: Premature ovarian failure affects fertility by leading to reduced or absent ovarian function, resulting in decreased estrogen production and irregular menstrual cycles.