Nokea
A pregnant, homeless woman who has received no prenatal care presents to the clinic in her third trimester because she is having vaginal bleeding but reports that she is not in pain. Ultrasound reveals a placenta previa. Which actions should the nurse implement?
- A. Schedule weekly prenatal appointments
- B. Contact social services for a temporary shelter
- C. Obtain a hemoglobin and hematocrit level
- D. Have the client transported to the hospital
Correct Answer: D
Rationale: Placenta previa requires hospitalization to monitor for bleeding (D).
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The nurse's assessment of a preterm infant reveals decreased muscle tone, signs of respiratory difficulty, irritability, and mottled, cool skin. Which intervention should the nurse implement first?
- A. Position radiant warmer over the crib
- B. Assess the infants blood glucose level
- C. Nipple feed 1 ounce 1% glucose in water
- D. Place the infant in side-lying position
Correct Answer: A
Rationale: A radiant warmer (A) helps stabilize the infant's temperature and provides immediate warmth.
A newborn, whose mother is HIV positive, is scheduled for follow-up assessments. The nurse knows that the most likely presenting symptom for a pediatric client with AIDS is:
- A. Shortness of breath
- B. Joint pain
- C. A persistent cold
- D. Organomegaly
Correct Answer: C
Rationale: Respiratory tract infections commonly occur in the pediatric population. However, the child with AIDS has a decreased ability to defend the body against these infections and often the presenting symptom of a child with AIDS is a persistent cold (C).
A patient postdelivery is concerned about getting back to her prepregnancy weight as soon as possible. She had only gained 15 lb during her pregnancy. Which assessment factor would be of concern at her 6-week postpartum checkup?
- A. Patient has lost 30 lb during the 6-week period prior to her scheduled checkup.
- B. Patient states that she is eating healthy and limiting intake of processed foods.
- C. Patient relates increased consumption of fruits and vegetables in her diet postbirth.
- D. Patient has resumed her usual exercise pattern of walking around the neighborhood for 10 minutes each night.
Correct Answer: A
Rationale: The correct answer is (A) because losing 30 lb in the 6-week postpartum period is concerning as it is excessive and may indicate underlying health issues like hyperthyroidism or inadequate nutrition. This rapid weight loss can also affect the mother's energy levels, milk production, and overall health.
Choice (B) is incorrect as eating healthy and limiting processed foods is a positive behavior that supports weight management. Choice (C) is also incorrect as increased consumption of fruits and vegetables is beneficial for overall health. Choice (D) is incorrect because resuming a light exercise routine like walking is generally encouraged postpartum, as long as it is done safely and does not lead to excessive strain.
To determine cultural influences on a patient's diet, what is the nurse's primary action?
- A. Evaluate the patient's weight gain during pregnancy.
- B. Assess the socioeconomic status of the patient.
- C. Discuss the four food groups with the patient.
- D. Identify the food preferences and methods of food preparation common to the patient's culture.
Correct Answer: D
Rationale: The correct answer is D because identifying the food preferences and methods of food preparation common to the patient's culture is crucial in understanding cultural influences on their diet. This step helps the nurse tailor dietary recommendations that align with the patient's cultural background and preferences, promoting better adherence and health outcomes.
Option A is incorrect as weight gain during pregnancy is not directly related to cultural influences on diet. Option B, assessing socioeconomic status, is important but not the primary action for understanding cultural influences on diet. Option C, discussing the four food groups, is too generic and does not specifically address cultural influences on diet.
The nurse assesses a client admitted to the labor and delivery unit and obtains the following data: dark red vaginal bleeding, uterus slightly tense between contractions, BP 110/68, FHR 110 beats/minute, cervix 1 cm dilated and uneffaced. Based on these assessment findings, what intervention should the nurse implement?
- A. Insert an internal fetal monitor
- B. Assess for cervical changes q1h
- C. Monitor bleeding from IV sites
- D. Perform Leopold's maneuvers
Correct Answer: C
Rationale: Monitoring bleeding from peripheral sites (C) is the priority intervention. This client is presenting with signs of placental abruption. Disseminated intravascular coagulation (DIC) is a complication of placental abruption, characterized by abnormal bleeding.