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A patient, 32 weeks pregnant with severe headache, is admitted to the hospital with preeclampsia. In addition to obtaining baseline vital signs and placing the client on bed rest, the physician ordered the following four items. Which of the orders should the nurse perform first?
- A. Assess deep tendon reflexes.'
- B. Obtain complete blood count.'
- C. Assess baseline weight.'
- D. Obtain routine urinalysis.'
Correct Answer: A
Rationale: The correct answer is A: Assess deep tendon reflexes. This is the priority because preeclampsia can progress to eclampsia, a life-threatening condition characterized by seizures. Assessing deep tendon reflexes helps in identifying signs of impending eclampsia. Obtaining a complete blood count (option B) and routine urinalysis (option D) are important in monitoring for complications of preeclampsia but do not address the immediate risk of seizures. Assessing baseline weight (option C) is also important but does not take precedence over assessing deep tendon reflexes in this scenario.
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An absence of what may facilitate the occurrence of bacterial vaginosis?
- A. Antibodies
- B. Lactobacillus acidophilus
- C. Gardnerella vaginalis
- D. Vaginal mucosa
Correct Answer: B
Rationale: Correct Answer: B - Lactobacillus acidophilus
Rationale: Lactobacillus acidophilus is a beneficial bacteria that helps maintain the acidic pH of the vagina, inhibiting the growth of harmful bacteria like Gardnerella vaginalis. An absence of Lactobacillus acidophilus can disrupt the vaginal microbiota balance, allowing for the overgrowth of harmful bacteria and leading to bacterial vaginosis.
Summary of Incorrect Choices:
A: Antibodies - Antibodies play a role in the immune response but are not directly related to the occurrence of bacterial vaginosis.
C: Gardnerella vaginalis - Gardnerella vaginalis is a bacteria associated with bacterial vaginosis, not its absence.
D: Vaginal mucosa - The integrity of the vaginal mucosa is important for protection, but its absence would not directly facilitate bacterial vaginosis.
When bathing an infant, what sign does the nurse recognize as a sign of developmental hip dysplasia?
- A. Hypotonicity of the leg muscles
- B. One leg is shorter than the other
- C. Broadening and flattening of the buttocks
- D. Two skinfolds on the back of each thigh
Correct Answer: B
Rationale: The correct answer is B: One leg is shorter than the other. This is a key sign of developmental hip dysplasia in infants. It indicates an imbalance in the hip joint, leading to unequal leg lengths. This can be detected during routine physical examinations by the nurse.
Incorrect choices:
A: Hypotonicity of the leg muscles - While muscle tone abnormalities can be associated with hip dysplasia, it is not a specific sign that is easily recognizable during bathing.
C: Broadening and flattening of the buttocks - This may be a sign of hip dysplasia in older children but is not a typical indicator in infants.
D: Two skinfolds on the back of each thigh - Although skinfolds can sometimes be present in infants with hip dysplasia, it is not a reliable or specific sign compared to the leg length discrepancy.
Which are risk factors for ovarian cancer? Select all that apply.
- A. Talc use on the perineum
- B. First-degree relative with ovarian cancer
- C. Three or more children
- D. High-fat diet
Correct Answer: C
Rationale: The correct answer is C: Three or more children. Multiparity (having three or more children) has been identified as a protective factor against ovarian cancer due to the repeated ovulation and hormonal changes during pregnancy. A: Talc use on the perineum is not a well-established risk factor. B: Having a first-degree relative with ovarian cancer increases the risk, but it is not as significant as having multiple children. D: High-fat diet has been suggested as a risk factor, but the evidence is not as strong as the protective effect of multiparity.
What is the clinical finding most likely to be exhibited in an infant diagnosed with erythroblastosis fetalis?
- A. Edema
- B. Immature red blood cells
- C. Enlargement of the heart
- D. Ascites
Correct Answer: B
Rationale: The correct answer is B: Immature red blood cells. Erythroblastosis fetalis is a condition where maternal antibodies attack fetal red blood cells, leading to hemolysis and the release of immature red blood cells (erythroblasts) into the circulation. This can result in anemia and jaundice in the infant. Edema (choice A) is not a typical clinical finding in erythroblastosis fetalis. Enlargement of the heart (choice C) is more commonly associated with conditions like congestive heart failure. Ascites (choice D) is the accumulation of fluid in the abdominal cavity and is not a characteristic finding in erythroblastosis fetalis.
List in order of priority the immediate postoperative mastectomy nursing actions.
- A. Elevate the affected arm with pillows above the level of the right atrium to promote comfort and lymphatic channel return.
- B. Assess vital signs, being careful not to use the affected arm for blood pressure measurement, and monitor parenteral fluids.
- C. Monitor for hemorrhage by assessing drainage from dressing and drainage tubes.
- D. Teach and reinforce the use of relaxation techniques to help reduce anxiety and provide distraction.
Correct Answer: B
Rationale: The correct answer is B because assessing vital signs and monitoring parenteral fluids are essential postoperative nursing actions to detect any signs of complications such as hemorrhage or fluid imbalance. This prioritizes the patient's physiological stability and safety. Elevating the affected arm (A) is important for comfort but not as immediate as monitoring vital signs. Monitoring for hemorrhage (C) is crucial but comes after ensuring the patient's physiological stability. Teaching relaxation techniques (D) is important for holistic care but is not as immediate as monitoring vital signs and fluid balance.