Nokea
A nurse is caring for a client who is in active labor and note the FHR baseline has been 100/min for the past 15 min. The nurse should identify which of the following conditions as a possible cause of fetal bradycardia?
- A. Maternal fever
- B. Fetal anemia
- C. Maternal hypoglycemia
- D. Chorioamnionitis
Correct Answer: B
Rationale: The correct answer is B: Fetal anemia. Fetal bradycardia (baseline <110/min) can be caused by inadequate oxygen delivery to the fetus, such as in fetal anemia. Anemia decreases the blood's ability to carry oxygen, leading to fetal distress. Maternal fever (A) can increase the fetal heart rate, not decrease it. Maternal hypoglycemia (C) can cause fetal distress, but typically presents with fetal tachycardia. Chorioamnionitis (D) can cause maternal fever and tachycardia, but is less likely to directly affect the fetal heart rate. Other choices are not provided.
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A nurse in an outpatient clinic is caring for a client.
Assessment
0840:
Client is calm and cooperative. Skin warm and dry. No rash noted. Lung sounds clear. Abdomen
soft to palpation with fundal height at 20 cm. Fetal heart rate 150/min. Bowel sounds active in all
four quadrants. No edema to lower extremities. Client denies visual changes or severe headaches.
Weight gain of 1.8 kg (4 lb) since last visit. Small amount of mucoid discharge noted on perineal
pad
Laboratory Results
0900:
Urine dipstick:
pH 6.0 mg/d (4.6 to 8 mg/dL)
Specific Gravity 1.022 (1.010 to 1.025)
Leukocyte esterase negative (Negative)
Nitrite negative (Negative)
Protein trace negative (Negative)
Glucose negative (Negative)
Ketones none (None)
Bilirubin none (None)
Blood none (None)
Nurses' Notes
0830:
Client reports to clinic for monthly prenatal visit. Client is at 20 weeks of gestation. Since last
visit, client reports concerns about the occurrence of intermittent mild backaches, increased
heartburn, generalized itching, and vaginal discharge.
Vital Signs
0830:
BP 124/68 mm Hg
Heart rate 80/min
Temperature 37° C (98.6° F)
Respiratory rate 16/min
Weight 67.1 kg (148 lb)
Which of the following statements should the nurse include in the client's teaching?
- A. Take hot showers to help relieve itching
- B. Wear flat or low-heeled shoes
- C. You can douche twice weekly
- D. Wear loose-fitting clothing
- E. Try using an abdominal support belt
- F. You should avoid fried foods
- G. Eat two large meals a day
Correct Answer: B,D,F
Rationale: Wearing flat shoes, wearing loose-fitting clothes, and avoiding fried foods are beneficial practices during pregnancy.
An occupational health nurse is providing teaching to a group of factory workers about proper lifting techniques.
Which statement should the nurse make?
- A. Bend at the waist when lifting objects from the floor.
- B. Keep the object close to your body when lifting.
- C. Twist your torso while lifting to maintain balance.
- D. Lift heavy objects quickly to reduce strain on the muscles.
Correct Answer: B
Rationale: The correct answer is B: Keep the object close to your body when lifting. This statement is correct because keeping the object close to the body reduces the strain on the back muscles and promotes proper lifting mechanics. By keeping the object close, the center of gravity is maintained, reducing the risk of injury.
Incorrect answers:
A: Bending at the waist when lifting can strain the lower back.
C: Twisting the torso while lifting can lead to back injuries.
D: Lifting heavy objects quickly can increase the risk of muscle strains and injuries.
Nurses' Notes
Day 1, 0915:
The client's adult child reports the client has not slept for 2 days and has become obsessed with
cleaning the house and hosting parties. At times the client is overly joyous and has a very
elevated sense of self-confidence. The adult child states that the client has also demonstrated
very impulsive spending habits and expresses concern about the client giving away large sums
of money to others.
The client's speech is very pressured, disorganized, and loud. Client unable to recall the last time
they ate.
Day 1, 0930:
Client questioned about their hallucinations and states that the same person has been following
them around inside and outside the house for days. Client asks the person what they want but
never receives an answer, Client states that this person has never told them to do anything: they
just stare and smile.
For each assessment finding, click to specify if the finding is consistent with psychosis or mania.
- A. Hallucinations
- B. Lack of sleep
- C. Excessive spending habits
- D. Disorganized thought process
- E. Pressured speech
Correct Answer: A,B,C,D,E
Rationale: The correct answer is A, B, C, D, E. Hallucinations, lack of sleep, excessive spending habits, disorganized thought process, and pressured speech are all consistent with both psychosis and mania. Hallucinations are sensory perceptions without a real external stimulus, common in both conditions. Lack of sleep is a hallmark symptom of mania and can also exacerbate psychotic symptoms. Excessive spending habits are often seen in manic episodes due to impulsivity, and disorganized thought process and pressured speech are characteristic of both psychosis and mania, reflecting the underlying cognitive and communication disturbances. Other choices are not specific or commonly associated with psychosis or mania.
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing. 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
- A. Instruct the client to avoid five vaccines
- B. Instruct the client to avoid foods high in purines
- C. Instruct the client to use mild soaps for cleansing skin.
- D. Gout
- E. Rheumatoid arthritis (RA)
- F. Systemic lupus erythematosus (SLE)
- G. ANA
Correct Answer: B
Rationale: Gout is characterized by elevated uric acid levels and responds to dietary modifications. Monitoring uric acid ensures treatment effectiveness.
A nurse is caring for a newborn.
Nurses' Notes
0640:
Weight 4200 gm (9 lb 4 oz), head circumference 35.5 cm (14 in)
Respiratory rate 68/min, with mild grunting.
0650:
Respiratory rate 72/min, with mild grunting
0700:
Respiratory rate 76/min, with moderate grunting and mild intercostal retractions.
The client is at risk for developing------- and----
- A. bronchopulmonary dysplasia
- B. transient tachypnea of the newborn
- C. tachycardia
- D. hypopycemia
Correct Answer: B,D
Rationale: Transient tachypnea and hypopycemia are common risks in newborns with respiratory distress.