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A nurse is completing the admission assessment of a newborn. Which of the following anatomical landmarks should the nurse use when measuring the newborn’s chest circumference?
- A. Intercostal space
- B. Xiphoid process
- C. Sternal notch
- D. Nipple line
Correct Answer: D
Rationale: The correct answer is D: Nipple line. When measuring a newborn's chest circumference, the nurse should use the nipple line as the anatomical landmark. This is because the nipple line is a consistent and reliable reference point for chest measurements in newborns. The other choices are not suitable landmarks for chest circumference measurement in newborns. A: Intercostal space is not a specific point for measurement. B: Xiphoid process is too low and not commonly used for chest measurements. C: Sternal notch is not a precise point for chest circumference measurement in newborns. Therefore, D: Nipple line is the most appropriate anatomical landmark for accurate chest circumference measurement in newborns.
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A nurse is caring for an adolescent client who is gravida 1 and para 0. The client was admitted to the hospital at 38 weeks of gestation with a diagnosis of preeclampsia. Which of the following findings should the nurse identify as inconsistent with preeclampsia?
- A. 3+ protein in the urine.
- B. Deep tendon reflexes of 1+.
- C. Blood pressure 148/98 mm Hg.
- D. 1+ pitting sacral edema.
Correct Answer: B
Rationale: The correct answer is B. Deep tendon reflexes of 1+ are inconsistent with preeclampsia. In preeclampsia, deep tendon reflexes are typically hyperactive (3+ or 4+). This is due to the central nervous system irritability caused by hypertension. Therefore, a reflex of 1+ suggests normal reflexes, which is not expected in preeclampsia. Other choices A, C, and D are consistent with preeclampsia. Proteinuria (choice A) is a hallmark sign of preeclampsia. Elevated blood pressure (choice C) is a common finding in preeclampsia. Pitting edema (choice D) is also commonly observed in preeclampsia due to fluid retention.
A nurse is caring for a client who has a suspected ectopic pregnancy at 8 weeks of gestation. Which of the following manifestations should the nurse expect to identify as consistent with the diagnosis?
- A. Large amount of vaginal bleeding
- B. Uterine enlargement greater than expected for gestational age
- C. Severe nausea and vomiting
- D. Unilateral, cramp-like abdominal pain
Correct Answer: D
Rationale: The correct answer is D. Unilateral, cramp-like abdominal pain is a classic symptom of an ectopic pregnancy. This pain occurs due to the fallopian tube stretching or rupturing as the embryo grows. This is different from a normal intrauterine pregnancy, where the pain would be central or bilateral.
A: Large amount of vaginal bleeding is not a typical symptom of an ectopic pregnancy.
B: Uterine enlargement greater than expected for gestational age would be seen in a normal intrauterine pregnancy, not an ectopic pregnancy.
C: Severe nausea and vomiting are common symptoms of early pregnancy but are not specific to ectopic pregnancy.
In summary, the key to identifying an ectopic pregnancy is recognizing the combination of abdominal pain and the location of the pain.
A nurse is caring for a client who is in premature labor and is receiving terbutaline. The nurse should monitor the client for which of the following adverse effects that should be reported to the provider?
- A. Dyspnea
- B. Headaches
- C. Nervousness
- D. Tremors
Correct Answer: A
Rationale: The correct answer is A: Dyspnea. Terbutaline is a beta-adrenergic agonist that can cause pulmonary edema as a serious adverse effect. Dyspnea is a common symptom of pulmonary edema, indicating potential respiratory distress. This adverse effect should be reported promptly to the provider for further evaluation and management to prevent complications.
Incorrect choices:
B: Headaches - Headaches are a common side effect of terbutaline but are not as concerning as respiratory distress.
C: Nervousness - Nervousness is a common side effect of terbutaline and does not typically require immediate reporting unless severe.
D: Tremors - Tremors are a common side effect of terbutaline and are not as concerning as respiratory distress.
A nurse on the obstetric unit is caring for a client who experienced abruptio placentae. The nurse observes petechiae and bleeding around the IV access site. The nurse should recognize that this client is at risk for which of the following complications?
- A. Preeclampsia
- B. Puerperal infection
- C. Anaphylactoid syndrome of pregnancy
- D. Disseminated intravascular coagulation
Correct Answer: D
Rationale: The correct answer is D: Disseminated intravascular coagulation (DIC). Abruptio placentae can lead to DIC due to the release of tissue factor, causing widespread clotting and consumption of clotting factors, leading to bleeding. Petechiae and bleeding around the IV site are signs of DIC. Preeclampsia (choice A) is a condition characterized by hypertension and proteinuria. Puerperal infection (choice B) is an infection that occurs after childbirth. Anaphylactoid syndrome of pregnancy (choice C) is a rare complication associated with amniotic fluid embolism. These complications are not directly related to the signs and symptoms described in the scenario.
A nurse in a prenatal clinic is caring for a client who is suspected of having a hydatidiform mole. Which of the following findings should the nurse expect to observe in this client?
- A. Rapid decline in human chorionic gonadotropin (hCG) levels
- B. Irregular fetal heart rate
- C. Excessive uterine enlargement
- D. Profuse, clear vaginal discharge
Correct Answer: C
Rationale: The correct answer is C: Excessive uterine enlargement. A hydatidiform mole is a gestational trophoblastic disease characterized by abnormal growth of placental tissue in the uterus, leading to excessive uterine enlargement. This condition results in the absence of a viable fetus and can cause symptoms such as vaginal bleeding, severe nausea, and hypertension. The other choices are incorrect because: A) Rapid decline in hCG levels is not a typical finding in a hydatidiform mole, as hCG levels are usually elevated. B) Irregular fetal heart rate is not applicable in this case since there is no viable fetus. D) Profuse, clear vaginal discharge is not a characteristic symptom of a hydatidiform mole. E, F, and G are not provided as options.