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A nurse is relieving the triage nurse in the labor and delivery unit who is going to lunch. The report indicates that there are three clients having their vital signs assessed and a fourth client is on her way to the unit from the emergency department. In which order of priority should the nurse manage these clients?
- A. The client with clear vesicles and brown vaginal discharge at 16 weeks' gestation.
- B. The client with right lower quadrant pain at 10 weeks' gestation.
- C. The client who is at term and has had no fetal movement for 2 days.
- D. The client from the emergency department at term and screaming loudly because of labor contractions.
Correct Answer: C,D,A,B
Rationale: The client with no fetal movement at term is the highest priority due to the risk of fetal distress. The client in active labor requires immediate attention. Vesicles and discharge suggest possible infection, and right lower quadrant pain may indicate ectopic pregnancy, both serious but less urgent.
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A female client with infertility related to anovulatory cycles is prescribed menotropins (Pergonal). Which of the following, if stated by the client as a possible adverse effect of this medication, indicates successful teaching?
- A. Pulmonary edema.
- B. Ovarian enlargement.
- C. Visual disturbances.
- D. Breast tenderness.
Correct Answer: B
Rationale: Menotropins stimulate ovarian follicle growth, which can lead to ovarian enlargement as a common adverse effect. Pulmonary edema, visual disturbances, and breast tenderness are not typically associated with this medication.
The nurse is providing bottle-feeding instructions to the mother of a newborn infant. The nurse provides instructions regarding the amount of formula to be given, knowing that what is the approximate stomach capacity for a newborn?
- A. 5 to 10 mL
- B. 10 to 20 mL
- C. 30 to 90 mL
- D. 75 to 100 mL
Correct Answer: B
Rationale: The stomach capacity of a newborn is approximately 10 to 20 mL. It is 30 to 90 mL for a 1-week-old infant and 75 to 100 mL for a 2- to 3-week-old infant.
The nurse is caring for a client who has just undergone a parathyroidectomy. Which of the following complications should the nurse monitor for in the immediate postoperative period?
- A. Hypocalcemia.
- B. Hyperglycemia.
- C. Hypertension.
- D. Weight loss.
Correct Answer: A
Rationale: Hypocalcemia is a potential complication post-parathyroidectomy due to reduced parathyroid hormone production.
You are caring for a multiple trauma client who has just arrived at the emergency room with a number of other external disaster victims. This client has multiple blast injuries and hypovolemic shock; it is anticipated that this unstable critically injured and unconscious client will have long term intravenous therapy, blood products and possibly hyperalimentation as well. Which type of venous access would you most likely anticipate for this client?
- A. A percutaneous, non tunneled subclavian catheter
- B. A peripheral intravenous catheter that is 20 gauge
- C. A multi lumen implanted tunneled and cuffed central venous catheter
- D. A peripherally inserted central venous catheter
Correct Answer: C
Rationale: A multi-lumen implanted tunneled and cuffed central venous catheter is most appropriate for long-term IV therapy, blood products, and hyperalimentation due to its durability and reduced infection risk.
The nurse is providing instructions to the parent of a child who had a myringotomy with insertion of tympanostomy tubes. Which instructions should the nurse provide the parent in case the tubes fall out?
- A. Bring the child to the emergency department immediately.
- B. It is not an emergency, but it is best to call the health care clinic.
- C. It is important to replace them immediately so that the surgical opening does not close.
- D. Clean the tubes with half-strength hydrogen peroxide for 30 minutes and then replace them into the child's ears.
Correct Answer: B
Rationale: The parent should be assured that if the tympanostomy tubes fall out, it is not an emergency, but it is best if the primary health care provider or health care clinic is notified. The size and appearance of the tympanostomy tubes should be described to the parent after surgery so that he or she will be familiar with their appearance. The remaining options are incorrect.