Nokea
A school nurse is providing teaching to an adolescent about levonorgestrel contraception. Which of the following information should the nurse include in the teaching?
- A. You should take the medication within 72 hours following unprotected sexual intercourse.
- B. You should avoid taking this medication if you are on an oral contraceptive.
- C. If you don't start your period within 5 days of taking this medication, you will need a pregnancy test.
- D. One dose of this medication will prevent you from becoming pregnant for 14 days after taking it.
Correct Answer: A
Rationale: The correct answer is A. Levonorgestrel is an emergency contraception pill effective if taken within 72 hours post unprotected sex. This is crucial information for the adolescent to prevent pregnancy. Choice B is incorrect as it does not interact with oral contraceptives. Choice C is incorrect as missing a period does not necessarily indicate pregnancy. Choice D is incorrect as it only provides immediate protection, not for 14 days.
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A nurse is assessing a full-term newborn upon admission to the nursery. Which of the following clinical findings should the nurse report to the provider?
- A. Single palmar creases (p200
- B. Down Syndrome)
- C. Rust-stained urine
- D. Transient circumoral cyanosis
- E. Subconjunctival hemorrhage
Correct Answer: A
Rationale: The correct answer is A: Single palmar creases. This finding is associated with Down Syndrome, which requires further evaluation by the provider. Single palmar creases are a physical characteristic commonly seen in infants with Down Syndrome. Reporting this to the provider allows for early intervention and appropriate management. Choices B, C, D, and E are incorrect because Down Syndrome (choice B) is not a clinical finding to report but rather a condition associated with single palmar creases. Rust-stained urine (choice C) may indicate hematuria but is not a common concern in newborns. Transient circumoral cyanosis (choice D) is a common finding in newborns that usually resolves on its own. Subconjunctival hemorrhage (choice E) is also a common and benign finding in newborns.
A nurse is reviewing the chart of a client who is 2 days postpartum following a vaginal delivery and reports constipation. Which of the following findings should the nurse identify as a contraindication to the use of a suppository?
- A. Vaginal candidiasis
- B. Abdominal distention
- C. Afterpains
- D. Third-degree perineal laceration
Correct Answer: D
Rationale: The correct answer is D: Third-degree perineal laceration. Using a suppository in a client with a third-degree perineal laceration can potentially worsen the injury and increase the risk of infection. The suppository insertion may cause trauma to the already compromised tissue, leading to further complications. It is crucial to avoid any interventions that can exacerbate the injury and hinder the healing process. Choices A, B, and C are not contraindications to using a suppository. Vaginal candidiasis, abdominal distention, and afterpains do not directly impact the safety or effectiveness of using a suppository in this scenario.
Which of the following findings should the nurse report to the provider? (Select all that apply.)
- A. Coombs test result
- B. Mucous membrane assessment
- C. Intake and output
- D. Respiratory rate
- E. Head assessment finding
- F. Heart rate
- G. Sclera color
Correct Answer: A,B,C,G
Rationale: The correct answers to report to the provider are A, B, C, and G. A Coombs test result should be reported as it indicates potential hemolytic anemia. Mucous membrane assessment is crucial for hydration status and oxygenation. Intake and output levels are key indicators of kidney function and hydration status. Sclera color can indicate liver function or anemia. Choices D, E, and F are important assessments but do not typically require immediate reporting unless they are outside of normal ranges and affecting the patient's condition.
A nurse is admitting a client to the birthing unit who reports her contractions started 1 hr ago. The nurse determines the client is 80% effaced and 8 cm dilated. The nurse realizes that the client is at risk for which of the following conditions?
- A. Ectopic pregnancy
- B. Hyperemesis gravidarum
- C. Incompetent cervix
- D. Postpartum hemorrhage
Correct Answer: D
Rationale: The correct answer is D: Postpartum hemorrhage. The client being 80% effaced and 8 cm dilated indicates she is in active labor, not at risk for ectopic pregnancy (A). Hyperemesis gravidarum (B) is severe nausea and vomiting during pregnancy, unrelated to cervical dilation. Incompetent cervix (C) is characterized by painless cervical dilation in the second trimester. Postpartum hemorrhage (D) is a risk due to the advanced cervical dilation and effacement, making it more likely for excessive bleeding during and after delivery.
A nurse is performing a routine assessment on a client who is at 18 weeks of gestation. Which of the following findings should the nurse expect?
- A. Deep tendon reflexes 4+
- B. Fundal height 14 cm
- C. Blood pressure 142/94 mm Hg
- D. FHR 152/min
Correct Answer: D
Rationale: The correct answer is D: FHR 152/min. At 18 weeks gestation, the fetal heart rate (FHR) typically ranges from 140-160 beats per minute, making 152/min within the normal range. This finding indicates a healthy fetal heart rate.
A: Deep tendon reflexes 4+ is not relevant to a routine assessment at 18 weeks gestation.
B: Fundal height of 14 cm is more indicative of around 12 weeks gestation, not 18 weeks.
C: Blood pressure of 142/94 mm Hg is elevated and would require further assessment and management, not expected at 18 weeks gestation.
In summary, the FHR of 152/min is the expected finding at 18 weeks gestation, making it the correct answer.