Nokea
An 8-year-old boy has been diagnosed with hemophilia. Which of the following diagnostic blood studies is characteristically abnormal in this disorder?
- A. Partial thromboplastin time
- B. Platelet count
- C. Complete blood count
- D. Bleeding time
Correct Answer: A
Rationale: Partial thromboplastic time measures activity of thromboplastin, which depends on the intrinsic clotting factors deficient in children who are hemophiliacs. Platelet counts are normal in hemophilia. Hemophilia does not affect the complete blood count. Bleeding times are normal in hemophiliacs. They measure the time interval for the bleeding from small superficial wounds to cease.
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A client delivered a term infant 1 hour ago. Her uterus on assessment is boggy and is U+1 in contrast to the previous assessment of U-2. The immediate nursing response is to:
- A. Administer methergine IM
- B. Remove the retained placental fragments
- C. Assist the client to the bathroom and provide cues to stimulate urination
- D. Massage the fundus until firm
Correct Answer: D
Rationale: Methergine is given following placental delivery to promote uterine contractions and prevent hemorrhage. Methergine may be administered in this clinical situation, but fundal massage would be the first response. Removal of retained placental fragments is done by the physician and is not the first response. If the fundus rises and is deviated, particularly to the right, the nurse should suspect bladder distention secondary to bladder and urethral trauma associated with birth and decreased bladder tone following delivery. Therefore, women have a diminished sensation to void. A boggy fundus rises and is indicative of blood pooling, predisposing the woman to clot formation. Massage the uterus until firm. Too vigorous massage will result in atonia. Clots may be expelled by a kneading motion of the uterus by the nurse.
A 22-year-old client is 16 weeks pregnant. She and her husband are expecting their first baby. The client tells the nurse that her last normal menstrual period was February 16, with 3 days of spotting on February 17, 18, and 19. The nurse calculates her expected date of delivery to be:
- A. November 23rd
- B. December 26th
- C. September 14th
- D. December 9th
Correct Answer: A
Rationale: Naegele's rule is as follows: add 7 days to the 1st day of the last menstrual period, subtract 3 months, and then add 1 year. Naegele's rule presumes that the woman has a 28-day menstrual cycle, with conception occurring on the 14th day of the cycle. Slight vaginal spotting may occur in early gestation for unknown reasons but is insignificant in the calculation of Naegele's rule. Naegele's rule presumes that the woman has a 28-day menstrual cycle, with conception occurring on the 14th day of the cycle. Slight vaginal spotting may occur in early gestation for unknown reasons but is insignificant in the calculation of Naegele's rule. Naegele's rule presumes that the woman has a 28-day menstrual cycle, with conception occurring on the 14th day of the cycle. Slight vaginal spotting may occur in early gestation for unknown reasons but is insignificant in the calculation of Naegele's rule.
The client is receiving total parenteral nutrition (TPN). Which assessment finding requires immediate action?
- A. Blood glucose of 200 mg/dL
- B. Weight gain of 1 pound in 24 hours
- C. Temperature of 99.8°F
- D. Dry, cracked lips
Correct Answer: A
Rationale: A blood glucose of 200 mg/dL indicates hyperglycemia, a common TPN complication requiring immediate action to adjust infusion or administer insulin. Weight gain, low-grade fever, and dry lips are less urgent.
The nurse is teaching circumcision care to the mother of a newborn. Which statement indicates that the mother needs further teaching?
- A. I will apply a petroleum gauze to the area with each diaper change.
- B. I will clean the area carefully with each diaper change.
- C. I can place a heat lamp to the area to speed up the healing process.
- D. I should carefully observe the area for signs of infection.
Correct Answer: C
Rationale: Using a heat lamp is incorrect and could cause burns or delay healing. Petroleum gauze, cleaning, and monitoring for infection are appropriate circumcision care practices.
The nurse is developing a plan of care for a client with a newly created ileostomy. The priority nursing diagnosis for this client is:
- A. Risk for deficient fluid volume related to excessive fluid loss from ostomy
- B. Disturbed body image related to presence of ostomy
- C. Risk for impaired skin integrity related to irritation from ostomy appliance
- D. Deficient knowledge of ostomy care related to unfamiliarity with information resources
Correct Answer: A
Rationale: Excessive fluid loss from a new ileostomy can lead to dehydration, making risk for deficient fluid volume the priority nursing diagnosis to ensure physiological stability.