Nokea
A nurse is caring for four antepartum clients. Which of the following clients should the nurse assess first?
- A. A client who is at 7 weeks of gestation and reports urinary frequency
- B. A client who is at 32 weeks of gestation and reports seeing floating spots
- C. A client who is 38 weeks of gestation and reports leg cramps
- D. A client who is at 20 weeks of gestation and reports periodic numbness in her fingers
Correct Answer: B
Rationale: The correct answer is B. The nurse should assess the client who is at 32 weeks of gestation and reports seeing floating spots first. Seeing floating spots could be a sign of preeclampsia, a serious pregnancy complication characterized by high blood pressure and organ damage. Preeclampsia can lead to severe complications for both the mother and the baby if not managed promptly. Therefore, this client needs immediate assessment to rule out preeclampsia and ensure appropriate interventions are initiated. Choices A, C, and D do not present with urgent signs or symptoms that require immediate attention compared to the potential severity of preeclampsia in choice B.
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A nurse is assessing a client during her first prenatal visit. The client reports March 20th as her last menstrual period. Use Nagele's rule to calculate the estimated date of delivery.
- A. 03/20
- B. 12/27
- C. 11/27
- D. 10/03
Correct Answer: B
Rationale: The correct answer is B: 12/27. Nagele's rule calculates the estimated due date by adding 7 days to the first day of the last menstrual period, then subtracting 3 months and adding 1 year. In this case, March 20th + 7 days = March 27th. Subtracting 3 months gives us December 27th. Adding 1 year, we get December 27th of the current year as the estimated due date. Choice A is incorrect because it does not follow Nagele's rule. Choice C is incorrect as it is not 3 months subtracted from the reported last menstrual period. Choice D is incorrect as it does not account for the necessary adjustments according to Nagele's rule.
A nurse is caring for newborn who is 1 hr old and has a respiratory rate of 50/min, a heart rate of 130/min, and an auxiliary temperature of 36.1*C (97F). Which of the following actions should the nurse take?
- A. Give the newborn a warm bath.
- B. Apply a cap to the newborn head.
- C. Reposition the newborn.
- D. Obtain an oxygen saturation level
Correct Answer: B
Rationale: The correct answer is B: Apply a cap to the newborn's head. This action helps prevent heat loss through the newborn's head, which is a common area for heat loss in newborns. The respiratory rate of 50/min and heart rate of 130/min are within normal ranges for a newborn. The temperature of 36.1°C (97°F) is slightly lower than the normal range, so keeping the newborn warm is important. Giving a warm bath (choice A) may further decrease the newborn's body temperature. Repositioning the newborn (choice C) may not address the issue of heat loss. Obtaining an oxygen saturation level (choice D) is not indicated based on the information provided. Therefore, applying a cap to the newborn's head is the most appropriate action to help maintain the newborn's body temperature and prevent heat loss.
A nurse is assessing a newborn immediately following a vaginal birth. For which of the following findings should the nurse intervene?
- A. Molding
- B. Vernix Caseosa
- C. Acrocyanosis
- D. Sternal retractions
Correct Answer: D
Rationale: The correct answer is D: Sternal retractions. Sternal retractions in a newborn indicate respiratory distress, potentially due to a blocked airway or difficulty breathing. The nurse should intervene immediately to ensure the newborn's airway is clear and that they are able to breathe properly.
A: Molding is the overlapping of cranial bones during birth, a common and temporary finding.
B: Vernix Caseosa is a protective coating on the newborn's skin and is normal.
C: Acrocyanosis is the bluish discoloration of the hands and feet, a common finding in newborns due to immature circulation.
A nurse caring for a client who is at 20 weeks of gestation and has trichomoniasis. Which of the following findings should the nurse expect?
- A. Thick, White Vaginal Discharge
- B. Urinary Frequency
- C. Vulva Lesions
- D. Malodorous Discharge
Correct Answer: D
Rationale: The correct answer is D: Malodorous Discharge. Trichomoniasis is a sexually transmitted infection caused by a parasite, typically presenting with a foul-smelling, greenish-yellow vaginal discharge. This discharge is a hallmark symptom of trichomoniasis due to inflammation and infection of the vaginal mucosa. Other choices are incorrect because: A) Thick, White Vaginal Discharge is more indicative of a yeast infection; B) Urinary Frequency is not a common symptom of trichomoniasis; C) Vulva Lesions are not typically associated with trichomoniasis at 20 weeks of gestation.
A nurse is assessing a newborn whose mother had a primary cytomegalovirus (CMV) infection during pregnancy. The newborn acquired CMV transplacentally. Which of the following findings should the nurse expect the newborn to exhibit?
- A. Urinary tract infection
- B. Hearing loss
- C. Macrosomia
- D. Cataracts
Correct Answer: B
Rationale: The correct answer is B: Hearing loss. CMV infection during pregnancy can lead to congenital CMV in newborns, resulting in various complications. Hearing loss is a common manifestation of congenital CMV infection. The virus can damage the inner ear structures, leading to sensorineural hearing loss. This complication is crucial to monitor and address early to prevent long-term consequences.
Incorrect choices:
A: Urinary tract infection - Not typically associated with congenital CMV infection.
C: Macrosomia - Excessive birth weight, not a common manifestation of congenital CMV infection.
D: Cataracts - Uncommon in congenital CMV infection; typically associated with other congenital infections like rubella.