Nokea
A nurse is teaching a client who is at 35 weeks of gestation about manifestations of potential pregnancy complications to report to the provider. Which of the following manifestations should the nurse include?
- A. Shortness of breath when climbing stairs.
- B. Swelling of feet and ankles at the end of the day.
- C. Headache that is unrelieved by analgesia.
- D. Braxton Hicks contractions.
Correct Answer: C
Rationale: The correct answer is C: Headache that is unrelieved by analgesia. This symptom could indicate a potentially serious condition such as preeclampsia, which requires immediate medical attention to prevent complications for the mother and baby. Shortness of breath when climbing stairs (A) is common in late pregnancy due to the growing uterus pressing on the diaphragm. Swelling of feet and ankles (B) is expected in pregnancy due to increased fluid retention. Braxton Hicks contractions (D) are normal and not a cause for concern unless they become regular and closer together.
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Which of the following nursing actions should the nurse plan to take? For each potential nursing action, click to specify it the intervention is indicated or contraindicated for the client.
- A. Insert a large bore intravenous catheter.
- B. Assess cervical dilation.
- C. Weigh perineal pads.
- D. Administer methotrexate.
Correct Answer: A, C
Rationale: [1, 0, 1], [0, 1, 0], [0, 0, 0], [0, 0, 1]
Inserting a large bore IV catheter is indicated for rapid fluid resuscitation. Weighing perineal pads helps monitor postpartum hemorrhage. Assessing cervical dilation and administering methotrexate are not appropriate in this scenario.
A nurse is caring for a newborn who is 70 hr old. Which of the following findings should the nurse report to the provider? (Select all that apply.)
- A. Respiratory findings
- B. Temperature
- C. Oxygen Saturation
- D. Central nervous system findings
- E. Gastrointestinal findings
Correct Answer: A, D, E
Rationale: The correct answers are A (Respiratory findings), D (Central nervous system findings), and E (Gastrointestinal findings). These are crucial areas to monitor in a newborn to ensure their well-being. Respiratory findings are important as newborns are prone to respiratory distress. Central nervous system findings are vital for assessing neurological status. Gastrointestinal findings are necessary to monitor feeding tolerance and bowel movements. Temperature, oxygen saturation, and other choices are also important but may not be as critical in this case. It is essential to focus on the key areas that can indicate potential issues and require immediate attention.
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. It is essential to maintain the client on bed rest to prevent further complications and to reduce the risk of dislodging the clot. Moving the affected leg could potentially dislodge the clot, leading to serious consequences such as pulmonary embolism. Administering aspirin for pain (choice A) is not appropriate as it can increase the risk of bleeding, especially in a patient receiving heparin. Massaging the affected leg (choice C) can also dislodge the clot and should be avoided. Applying cold compresses (choice D) can potentially exacerbate the situation by causing vasoconstriction and increasing the risk of clot formation.
The nurse suspects the adolescent is experiencing pelvic inflammatory disease and is planning care. Which of the following prescriptions should the nurse expect the provider to prescribe? Drag words from the choices below to fill in each blank in the following sentence. The nurse should anticipate a provider's prescription for---------------------- and ------------------
- A. doxycydline
- B. acyclovir
- C. imiquimod
- D. fluconazole
- E. ceftriaxone
- F. Providing education on medications
Correct Answer: A,E,F
Rationale: The correct answer is A, E, and F. Pelvic inflammatory disease is commonly caused by sexually transmitted infections, such as Chlamydia and Gonorrhea. The recommended treatment involves antibiotics like doxycycline (A) and ceftriaxone (E) to target these infections. Providing education on medications (F) is essential to ensure compliance and understanding of the treatment regimen. Acyclovir (B) is used to treat herpes infections, not PID. Imiquimod (C) is used for certain skin conditions, not PID. Fluconazole (D) is an antifungal medication, not typically used for PID treatment.
A nurse is assessing a client who is at 30 weeks of gestation during a routine prenatal visit. Which of the following findings should the nurse report to the provider?
- A. Swelling of the face.
- B. Varicose veins in the calves.
- C. Nonpitting 1+ ankle edema.
- D. Hyperpigmentation of the cheeks.
Correct Answer: A
Rationale: The correct answer is A: Swelling of the face. Facial swelling in pregnancy could be a sign of preeclampsia, a serious condition characterized by high blood pressure and protein in the urine. This requires immediate medical attention to prevent complications for both the mother and the baby. Varicose veins in the calves (B) are common in pregnancy but do not pose an immediate threat. Nonpitting 1+ ankle edema (C) is a common finding in pregnancy and typically not concerning unless it worsens. Hyperpigmentation of the cheeks (D) is also a common occurrence during pregnancy known as "the mask of pregnancy" and is not a cause for alarm.