Nokea
A woman in the first trimester comes to the clinic with vaginal bleeding. The physician determines that the fetus has died and that the placenta, fetus, and tissues still remain in the uterus. How should the findings be documented?
- A. Complete abortion
- B. Stillborn abortion
- C. Missed abortion
- D. Incomplete abortion
Correct Answer: C
Rationale: The correct answer is C: Missed abortion. In a missed abortion, the fetus has died but has not been expelled from the uterus yet. The findings should be documented as a missed abortion because the fetus has not been passed naturally. This is different from a complete abortion (A) where all products of conception have been expelled, a stillborn abortion (B) which is not a recognized medical term, and an incomplete abortion (D) where some products of conception remain in the uterus. Therefore, based on the scenario described, the most appropriate term to document the findings is missed abortion.
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Which physiological change takes place during the puerperium?
- A. The endometrium begins to undergo alterations necessary for menstruation.
- B. The placenta begins to separate from the uterine wall.
- C. The uterus returns to a pre-pregnant size and location.
- D. The uterus contracts at regular intervals with dilation of the cervix occurring.
Correct Answer: C
Rationale: During the puerperium, the correct physiological change is that the uterus returns to a pre-pregnant size and location (Choice C). This is because after childbirth, the uterus undergoes involution, gradually decreasing in size back to its pre-pregnant state. This process involves the shedding of excess tissue and contraction of uterine muscles. The endometrium (Choice A) does not undergo alterations for menstruation until after the puerperium, as menstruation typically resumes around 6-8 weeks postpartum. The placenta (Choice B) should have been expelled completely during the third stage of labor, so it does not separate during the puerperium. The uterus does contract, but it is not at regular intervals with cervical dilation (Choice D) during the puerperium.
A nurse is preparing a room for the admission of a client with sickle cell anemia who is in vasoocclusive crisis. Which type of equipment should the nurse place in the client's room?
- A. Wheelchair with adjustable leg rests
- B. A radio and age-appropriate reading materials
- C. Extra blankets and pillows
- D. Blood transfusion equipment
Correct Answer: D
Rationale: The correct answer is D: Blood transfusion equipment. In a vasoocclusive crisis, the client with sickle cell anemia may require blood transfusions to improve oxygen delivery to tissues. Having blood transfusion equipment readily available in the client's room ensures prompt initiation of treatment. Wheelchair (A) and comfort items like extra blankets and pillows (C) are important but not essential during a vasoocclusive crisis. A radio and reading materials (B) are not directly related to the client's immediate medical needs.
A nurse in the clinic instructs a primigravida about the danger signs of pregnancy. The client demonstrates understanding of the instructions, stating she will notify the physician if which sign occurs?
- A. White vaginal discharge
- B. Dull backache
- C. Frequent,urgent urination
- D. Abdominal pain
Correct Answer: D
Rationale: The correct answer is D: Abdominal pain. Abdominal pain is a significant danger sign in pregnancy that could indicate various complications such as ectopic pregnancy, placental abruption, or preterm labor. Prompt medical evaluation is crucial to ensure the health of both the mother and the baby. White vaginal discharge (A) is not necessarily a danger sign unless it is accompanied by other symptoms like itching or a foul smell. Dull backache (B) is common in pregnancy and usually not a cause for concern unless severe or accompanied by other symptoms. Frequent, urgent urination (C) is a common symptom in pregnancy due to increased pressure on the bladder and is not typically a danger sign unless associated with pain or burning.
A client delivered vaginally six hours ago. Which assessment finding can be interpreted as normal?
- A. Temperature 100.0 degrees F
- B. Blood pressure 140/90
- C. Respirations 10
- D. Pulse 90
Correct Answer: A
Rationale: The correct answer is A: Temperature 100.0 degrees F. This finding can be interpreted as normal because a slight increase in body temperature after childbirth is expected due to the physiological changes during labor. A temperature of 100.0 degrees F is within the normal range for postpartum women.
Rationale for why the other choices are incorrect:
B: Blood pressure 140/90 - This blood pressure reading is slightly elevated and may indicate hypertension, which would not be considered normal postpartum.
C: Respirations 10 - A respiratory rate of 10 is abnormally low and could indicate respiratory distress rather than normal postpartum recovery.
D: Pulse 90 - A pulse rate of 90 may be within normal limits, but it is not as indicative of normal postpartum recovery as a slightly elevated temperature would be.
A nurse is preparing to admit a 15-year-old client with HIV/AIDS. Based on the client's diagnosis, which of the following nursing actions is appropriate?
- A. Contribute to planning client education on standard precautions in age-appropriate manner.
- B. Contact the dietary department to request foods be delivered on disposable dishes.
- C. Prepare for infection control in a negative pressure room for this client.
- D. Instruct visitors to wear gowns and masks when entering the client's room.
Correct Answer: A
Rationale: Correct Answer: A
Rationale:
1. Client education on standard precautions is crucial to prevent the spread of infections.
2. The nurse should tailor the education in an age-appropriate manner to ensure understanding.
3. Contributing to planning education empowers the client to take an active role in their health.
4. This action promotes client safety and reduces the risk of transmission to others.
Summary:
B: Contacting the dietary department for disposable dishes is not directly related to HIV/AIDS education or infection control.
C: Preparing a negative pressure room is not necessary for standard precautions and may not be feasible in all settings.
D: Instructing visitors to wear gowns and masks is excessive for standard precautions and may cause distress to the client.