Nokea
A nurse is planning a presentation about HIV for a church-based group. Which of the following information about HIV transmission should the nurse include?
- A. It is primarily transmitted through mosquitoes.
- B. It is primarily transmitted through accidental puncture wounds.
- C. It is primarily transmitted through sexual contact.
- D. It is primarily transmitted through respiratory droplets.
Correct Answer: C
Rationale: HIV is primarily transmitted through sexual contact involving infected fluids like semen or vaginal secretions. Mosquitoes, respiratory droplets, and puncture wounds (rare) don't commonly spread HIV.
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A nurse is providing prenatal care to a pregnant client. At which time would the nurse expect to screen the client for group B streptococcus infection?
- A. 28 weeks' gestation
- B. 32 weeks' gestation
- C. 16 weeks' gestation
- D. 36 weeks' gestation
Correct Answer: D
Rationale: Screening for group B streptococcus (GBS) is done at 35-37 weeks (36 weeks is closest) to assess colonization status near delivery, guiding intrapartum antibiotic use to prevent neonatal infection. Earlier screening (16, 28, or 32 weeks) may not reflect status at birth, as GBS colonization can change.
A pregnant client in her second trimester has a hemoglobin level of 11 g/dL. The nurse interprets this as indicating
- A. Hemodilution of pregnancy
- B. A multiple gestation pregnancy
- C. Greater-than-expected weight gain
- D. Iron-deficiency anemia
Correct Answer: A
Rationale: Hemodilution of pregnancy occurs as plasma volume increases more than red blood cell mass, lowering hemoglobin to 10.5-14 g/dL in the second trimester, which includes 11 g/dL. Multiple gestation may raise hemoglobin, weight gain doesn't affect it, and iron-deficiency anemia typically shows lower hemoglobin with symptoms like fatigue.
A nurse is caring for a client who has an NG tube set to low intermittent suction. The nurse irrigates the NG tube twice with 30 mL of normal saline solution during his shift. At the end of the shift, the NG canister contains 475 mL. What amount of NG drainage should the nurse record?
- A. 415 mL
- B. 475 mL
- C. 445 mL
- D. 430 mL
Correct Answer: A
Rationale: NG drainage = canister fluid (475 mL) minus irrigation (2 x 30 mL = 60 mL) = 415 mL. Recording irrigation fluid as drainage would inflate the output inaccurately.
Assessment of a pregnant woman reveals oligohydramnios. The nurse would be alert for the development of which condition?
- A. Maternal diabetes
- B. Fetal anencephaly
- C. Placental abruption
- D. Neural tube defects
Correct Answer: B
Rationale: Oligohydramnios (low amniotic fluid) is linked to fetal anencephaly, where absent brain development reduces fetal urine, a fluid source. Maternal diabetes causes polyhydramnios, abruption affects bleeding, and neural tube defects don't directly reduce fluid.
A nurse suspects that a pregnant client may be experiencing placenta abruption based on which finding? Select all that apply.
- A. Absence of pain
- B. Insidious onset
- C. Dark red vaginal bleeding
- D. Rigid uterus
- E. Absent fetal heart tones
Correct Answer: C,D,E
Rationale: Placental abruption involves sudden separation of the placenta, causing severe pain, a rigid uterus from bleeding, dark red vaginal bleeding due to clotted blood, and absent fetal heart tones if the fetus is compromised. Absence of pain and insidious onset are not typical, as abruption is acute and painful.