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A nurse is performing a routine assessment on a client who is at 18 weeks of gestation. Which of the following findings should the nurse expect?
- A. Deep tendon reflexes 4+.
- B. Fundal height 14 cm.
- C. Blood pressure 142/94 mm Hg.
- D. FHR 152/min.
Correct Answer: D
Rationale: The correct answer is D: FHR 152/min. At 18 weeks gestation, a normal fetal heart rate (FHR) ranges from 120-160/min. This is indicative of a healthy fetus. A: Deep tendon reflexes 4+ is not a typical finding during a routine assessment in pregnancy. B: Fundal height of 14 cm is more consistent with around 12-13 weeks gestation, not 18 weeks. C: Blood pressure of 142/94 mm Hg is elevated and may indicate hypertension, which is not expected at this stage of pregnancy.
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A nurse is providing discharge teaching about car seat safety to a parent of a newborn. Which of the following statements by the parent indicates an understanding of the teaching?
- A. “I will position my baby at a 45-degree angle in the car seat.
- B. I can place my baby in the front seat with the airbag turned off.
- C. I can turn my baby's car seat around when she weighs 15 pounds.
- D. I will place my baby in a forward-facing car seat in my back seat.
Correct Answer: A
Rationale: Correct Answer: A. "I will position my baby at a 45-degree angle in the car seat."
Rationale: Placing the newborn at a 45-degree angle in the car seat supports the baby's airway and prevents slumping, ensuring proper breathing and safety. This position helps reduce the risk of suffocation and allows the baby's head to be supported. It is recommended by pediatric experts as the safest way for a newborn to travel in a car seat.
Summary of other choices:
B: Placing a baby in the front seat with the airbag turned off is not safe, as the back seat is the safest place for children under 13 years old.
C: Turning the baby's car seat around at 15 pounds is incorrect as rear-facing is recommended until at least 2 years of age.
D: Using a forward-facing car seat for a newborn is unsafe, as infants should be in a rear-facing seat until they outgrow the height or weight limit.
A nurse is assessing a client who is postpartum and has idiopathic thrombocytopenia purpura (ITP). Which of the following findings should the nurse expect?
- A. Decreased platelet count.
- B. Increased erythrocyte sedimentation rate (ESR).
- C. Decreased megakaryocytes.
- D. Increased WBC.
Correct Answer: A
Rationale: The correct answer is A: Decreased platelet count. In idiopathic thrombocytopenia purpura (ITP), there is a decrease in platelet count due to immune-mediated destruction of platelets. This can lead to an increased risk of bleeding.
Explanation for other choices:
B: Increased erythrocyte sedimentation rate (ESR) is not typically associated with ITP.
C: Decreased megakaryocytes may be seen in some cases of ITP but is not a consistent finding.
D: Increased WBC is not a characteristic finding in ITP.
Therefore, the most relevant finding in a client with ITP would be a decreased platelet count due to the underlying pathophysiology of the condition.
A nurse is assessing a newborn 12 hr after birth. Which of the following manifestations should the nurse report to the provider?
- A. Acrocyanosis.
- B. Transient strabismus.
- C. Jaundice.
- D. Caput succedaneum.
Correct Answer: C
Rationale: The correct answer is C: Jaundice. Jaundice in a newborn within the first 24 hours may indicate pathological conditions such as hemolytic disease or liver dysfunction. It requires immediate evaluation and treatment. Acrocyanosis (A) is a common finding in newborns due to immature circulation. Transient strabismus (B) is often seen in newborns and typically resolves on its own. Caput succedaneum (D) is swelling on the newborn's scalp from pressure during birth, which is a normal finding.
A nurse is caring for a postpartum client who is receiving heparin via a continuous IV infusion for thrombophlebitis in their left calf. Which of the following actions should the nurse take?
- A. Administer aspirin for pain.
- B. Maintain the client on bed rest.
- C. Massage the affected leg every 12 hr.
- D. Apply cold compresses to the affected calf.
Correct Answer: B
Rationale: The correct answer is B: Maintain the client on bed rest. In a client receiving heparin for thrombophlebitis, bed rest is essential to prevent dislodgment of the clot and avoid further complications. Moving around can increase the risk of embolism. Administering aspirin (choice A) is not recommended as it can increase the risk of bleeding with heparin. Massaging the affected leg (choice C) can dislodge the clot leading to embolism. Applying cold compresses (choice D) can also increase the risk of dislodging the clot. The key is to promote circulation without dislodging the clot, which is achieved by keeping the client on bed rest.
The nurse is reviewing laboratory results in the adolescent's medical
record.
Exhibit 1
Vital Signs
1300:
Blood pressure 118/72 mm Hg
Heart rate 100/min
Respiratory rate 20/min
Temperature 38.3° C (101° F)
The nurse is reviewing the adolescent's medical record. Which of the following conditions is the client most likely developing? Complete the following sentence by using the list of options. The adolescent is most likely developing -------------------------- evidenced by --------------------------
- A. Pelvic inflammatory disease
- B. Ectopic pregnancy
- C. C-reactive protein
- D. Beta hCG level
- E. Urinalysis
Correct Answer:
Rationale: Correct Answer: A: Pelvic inflammatory disease
Rationale: Pelvic inflammatory disease (PID) is a common condition in adolescents due to sexually transmitted infections. The nurse reviewing the medical record indicates a focus on the reproductive system. Ectopic pregnancy and Beta hCG levels are related but not the most likely in this case. C-reactive protein and urinalysis are general tests not specific to PID.