Duration of latent phase in a multigravida is:
- A. 1-2 hours.
- B. 2-4 hours.
- C. 4-6 hours.
- D. 6-8 hours.
- E. 8-10 hours.
Correct Answer: C
Rationale: The latent phase in multigravida typically lasts 4-6 hours shorter than in primigravida due to prior cervical changes. Other durations are less common.
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The nurse would be correct to set the infusion pump for which hourly rate?
- A. 50 mL
- B. 75 mL
- C. 100 mL
- D. 125 mL
Correct Answer: D
Rationale: The order is 1,000 mL over 8 hours. Dividing 1,000 by 8 gives 125 mL/hour, the correct rate for the infusion pump.
The nurse is concerned that a newborn may have congenital hydrocephalus. Which finding did the nurse likely observe on assessment?
- A. Bulging anterior fontanel
- B. Head and chest circumference equal
- C. A narrowed posterior fontanel
- D. Low-set ears
Correct Answer: A
Rationale: A bulging anterior fontanel suggests hydrocephalus due to increased intracranial pressure. Equal head/chest circumferences narrow posterior fontanel and low-set ears are normal or unrelated.
Which explanation by the nurse is most accurate?
- A. Your child's condition, which involves a 35-degree curvature, may improve without treatment.
- B. Your child may develop problems with bladder control without treatment.
- C. Your child may develop problems with bowel control without treatment.
- D. Your child may develop breathing problems without treatment.
Correct Answer: D
Rationale: A 35-degree scoliosis curvature is significant and, without treatment, may progress, potentially compressing the lungs and causing breathing difficulties.
Which instruction is most appropriate to give to the client regarding doxycycline?
- A. The medication normally causes a dark orange discoloration of urine.
- B. Take the medication 1 hour before or 2 hours after a meal.
- C. Don't drink water for at least 30 minutes after taking the medication.
- D. Report any symptoms of GI upset to the health care provider.
Correct Answer: B
Rationale: Doxycycline should be taken on an empty stomach (1 hour before or 2 hours after a meal) to ensure optimal absorption, making this the most appropriate instruction.
The first-time mother of the 2-hour-old full-term newborn worriedly tells the nurse,“Something black is coming out of my baby.” After determining that the newborn has passed stool which statement by the nurse is most appropriate?
- A. “Black stools could be from bleeding. I will notify your provider now.”
- B. “Breastfeeding will cause all the baby’s stools to be this dark in color.”
- C. “Babies normally pass this type of stool initially; it is called meconium.”
- D. “I’ll check the baby’s temperature; this occurs when babies need warming.”
Correct Answer: C
Rationale: Meconium a greenish-black stool is normal within 24 hours after birth formed from amniotic fluid and intestinal secretions. It’s not related to bleeding breastfeeding or temperature.
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