Nokea
A nurse is collecting data from a client who is at 30 weeks of gestation. Which of the following findings should the nurse identify as a manifestation of pyelonephritis?
- A. Epigastric discomfort
- B. Flank pain
- C. Temperature 37.7°C (99.8°F)
- D. Abdominal cramping
Correct Answer: B
Rationale: The correct answer is B: Flank pain. Pyelonephritis is an infection of the kidneys, which commonly presents with symptoms like flank pain. This pain is typically described as a dull ache in the lower back or sides. Other options are incorrect because: A) Epigastric discomfort is more indicative of gastrointestinal issues; C) A temperature of 37.7°C (99.8°F) is within normal range and not specific to pyelonephritis; D) Abdominal cramping is more likely related to gastrointestinal or uterine issues in pregnancy.
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A nurse is providing teaching to a client who is at 35 weeks of gestation and has a prescription for an amniocentesis. Which of the following client statements indicates an understanding of the teaching?
- A. I should empty my bladder before the procedure.
- B. I will be lying on my side during the procedure.
- C. I will be asleep during the procedure.
- D. I should start fasting 24 hours before the procedure.
Correct Answer: A
Rationale: The correct answer is A: "I should empty my bladder before the procedure." This statement indicates understanding because a full bladder can obstruct visualization during amniocentesis. Choice B is incorrect because the client should lie flat on their back during the procedure. Choice C is incorrect as the client is awake for an amniocentesis. Choice D is incorrect because fasting is not required before the procedure.
A nurse is providing prenatal teaching to a client who practices a vegan diet and is trying to increase intake of vitamin B12. Which of the following foods should the nurse recommend?
- A. Fortified soy milk
- B. Raw carrots
- C. Fresh citrus fruits
- D. Brown rice
Correct Answer: A
Rationale: The correct answer is A: Fortified soy milk. Vegans often have difficulty obtaining enough vitamin B12, which is primarily found in animal products. Fortified soy milk is a good source of vitamin B12 for vegans. Raw carrots (B), fresh citrus fruits (C), and brown rice (D) do not contain significant amounts of vitamin B12. Raw carrots and fresh citrus fruits are good sources of vitamin C, while brown rice is a source of carbohydrates and fiber.
Which of the following hormones stimulates ovulation?
- A. Progesterone
- B. Estrogen
- C. Luteinizing hormone (LH)
- D. Follicle-stimulating hormone (FSH)
Correct Answer: C
Rationale: Luteinizing hormone (LH) is responsible for triggering ovulation by stimulating the release of an egg from the ovary. This is a key part of the menstrual cycle.
A nurse is caring for an infant who has signs of neonatal abstinence syndrome. Which of the following actions should the nurse take?
- A. Monitor blood glucose level every hr.
- B. Place the infant on his back with legs extended.
- C. Initiate seizure precautions.
- D. Provide a stimulating environment.
Correct Answer: C
Rationale: The correct answer is C: Initiate seizure precautions. The infant with neonatal abstinence syndrome is at risk for seizures due to drug withdrawal. By initiating seizure precautions, the nurse can ensure the safety of the infant by implementing measures such as padding the crib, having emergency medications readily available, and closely monitoring for any signs of seizure activity.
Choice A is incorrect because monitoring blood glucose levels every hour is not typically indicated for neonatal abstinence syndrome. Choice B is incorrect as placing the infant on his back with legs extended does not address the risk of seizures. Choice D is incorrect as providing a stimulating environment can exacerbate the symptoms of withdrawal.
A nurse is preparing to administer oxytocin to a client who is postpartum. Which of the following findings is an indication for the administration of the medication? (Select all that apply.)
- A. Flaccid uterus
- B. Cervical laceration
- C. Excess vaginal bleeding
- D. Increased afterbirth cramping
Correct Answer: A,C
Rationale: Oxytocin is administered postpartum to manage uterine atony (flaccid uterus) and control excessive bleeding, which are common indications for its use.