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During a routine first trimester prenatal exam, a pregnant client tells the nurse that she has noticed an increase in vaginal discharge that is white, thin, and watery. Which action should the nurse implement?
- A. Notify the healthcare provider of the complaint
- B. Recommend an over-the-counter yeast medication
- C. Inform her that this is a normal physiological change.
- D. Prepare the client for a sterile speculum exam
Correct Answer: C
Rationale: Increased white, thin, watery discharge (leukorrhea) is a normal physiological change in pregnancy due to hormonal shifts, requiring no immediate intervention.
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A client at 40-weeks gestation is admitted in active labor, and laboratory findings indicate that she is HIV positive. Which actions should the nurse plan to perform? (Select all that apply.)
- A. Place client in a negative pressure room
- B. Implement droplet precautions
- C. Encourage the mother to bottle-feed
- D. Give antiviral medication intravenously
- E. Use standard precautions
Correct Answer: C,D,E
Rationale: HIV is transmitted through blood, body fluids, or breast milk, not air or droplets. Bottle-feeding (C) prevents transmission via breast milk, IV antiviral medication (D) reduces perinatal transmission, and standard precautions (E) are sufficient for infection control.
The nurse is caring for a client who delivered 6 hours ago. Assessment findings reveal a boggy uterus that is displaced above and to the right of the umbilicus. Which action should the nurse take?
- A. Encourage voiding
- B. Notify healthcare provider
- C. Inspect the perineal pad
- D. Monitor vital signs
Correct Answer: A
Rationale: A boggy uterus displaced above and to the right of the umbilicus often indicates a distended bladder, which can prevent proper uterine contraction. Encouraging voiding addresses this issue, helping the uterus return to its normal position and firm up.
During the newborn admission assessment, the nurse palpates the newborn's scrotum and does not feel the testicles. Which assessment technique should the nurse perform next to verify the absence of testes?
- A. Use a fingertip to palpate the inguinal canal for a weakening or indentation
- B. Measure the size of the scrotal sac for length and width.
- C. Perform transillumination of the scrotal sac to visualize shadows of the testes
- D. Observe the urethral opening on the surface of the penis when the newborn voids
Correct Answer: A
Rationale: Palpating the inguinal canal is the next step to check for undescended testes, which may be located in the inguinal area.
Assessment findings of a 4-hour-old newborn include: axillary temperature of 96.8° F (35.8° C), heart rate of 150 beats/minute with a soft murmur, irregular respiratory rate at 64 breaths/minute, jitteriness, hypotonic and weak cry. Based on these findings, which action should the nurse implement?
- A. Document the findings in the record
- B. Obtain a heel stick blood glucose level.
- C. Place a pulse oximeter on the heel.
- D. Swaddle the infant in a warm blanket
Correct Answer: B
Rationale: Jitteriness, hypotonia, and a weak cry suggest possible hypoglycemia, a critical condition requiring immediate blood glucose testing.
The nurse is caring for a client who is 24-weeks gestation and reports increased thirst and urination. Which diagnostic test result should the nurse report to the healthcare provider?
- A. Hemoglobin A1C.
- B. Postprandial blood glucose test
- C. Fasting blood glucose
- D. Oral glucose tolerance test
Correct Answer: C
Rationale: Increased thirst and urination at 24 weeks suggest possible gestational diabetes. Fasting blood glucose is a standard initial screening test to detect abnormal glucose levels.