Nokea
A nurse is caring for a client who might have a hydatidiform mole. The nurse should monitor the client for which of the following findings?
- A. Fetal heart rate irregularities.
- B. Whitish vaginal discharge.
- C. Rapidly dropping human chorionic gonadotropin (hCG) levels.
- D. Excessive uterine enlargement.
Correct Answer: D
Rationale: Excessive uterine enlargement is a key sign of hydatidiform mole due to trophoblastic tissue overgrowth. Fetal heart rate irregularities are absent as there's typically no viable fetus, and hCG levels are high, not dropping. Bleeding, not whitish discharge, is common.
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A nurse is assisting with the care of a newborn 1 hr after birth. Select the 5 findings that the nurse should report to the provider.
- A. Temperature
- B. Respiratory findings
- C. Serum glucose
- D. Hematocrit
- E. White blood cell count
- F. Hemoglobin
- G. Heart rate
Correct Answer: B,G
Rationale: High respiratory rate (80-84/min) and low oxygen saturation (96%) suggest respiratory distress. Elevated heart rate (174-178/min) indicates tachycardia, possibly from stress or hypoxia. Other findings lack abnormal data or specific values.
What is the most significant risk factor for clubfoot?
- A. Smoking
- B. Trauma during pregnancy
- C. Hypertension
- D. Decreased circulation
Correct Answer: A
Rationale: Maternal smoking during pregnancy is strongly associated with clubfoot, likely affecting fetal muscle and tendon development. Trauma, hypertension, and decreased circulation lack evidence as significant risk factors for this congenital condition.
A nurse is assisting with monitoring a client who has preeclampsia and is receiving magnesium sulfate. The client's respiratory rate is 8/min. Which of the following should the nurse administer?
- A. Protamine sulfate
- B. Naloxone
- C. Flumazenil
- D. Calcium gluconate
Correct Answer: D
Rationale: Respiratory depression (8/min) indicates magnesium sulfate toxicity. Calcium gluconate is the antidote, stabilizing cell membranes and counteracting magnesium's effects. Protamine sulfate, naloxone, and flumazenil treat other overdoses, not magnesium toxicity.
A nurse is reinforcing teaching with a new mother about the purpose of administering vitamin K to her newborn following delivery. The nurse should explain that the purpose of administering vitamin K is to prevent which of the following complications?
- A. Infection
- B. Hyperbilirubinemia
- C. Bleeding
- D. Potassium deficiency
Correct Answer: C
Rationale: Vitamin K prevents bleeding (hemorrhagic disease of the newborn) by aiding clotting factor synthesis, as newborns have low vitamin K levels. It does not prevent infection, hyperbilirubinemia, or potassium deficiency.
A nurse is caring for a client who wants to know if it is possible to have a vaginal birth after a cesarean birth (VBAC). Which of the following statements by the nurse is appropriate?
- A. There are so many variables that you'll have to ask your provider.
- B. A repeat cesarean section would be safer for both you and your baby.
- C. The primary consideration is what type of incision you had.
- D. It's too soon for you to be worrying about that now.
Correct Answer: C
Rationale: The type of uterine incision (e.g., low transverse vs. classical) is critical for VBAC eligibility due to rupture risk. Dismissing the question, deferring entirely, or assuming cesarean safety without evidence is inappropriate.