Nokea
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.
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A client who is 32 weeks gestation comes to the women's health clinic and reports nausea and vomiting. On examination, the nurse notes that the client has an elevated blood pressure. Which action should the nurse implement next?
- A. Inspect the client's face for edema
- B. Ascertain the frequency of headaches
- C. Evaluate for history of cluster headaches
- D. Observe and time client's contractions
Correct Answer: A
Rationale: Elevated blood pressure at 32 weeks may suggest preeclampsia. Inspecting for facial edema is a priority to assess for fluid retention, a key sign of this condition.
A pregnant client receives Rho(D) immune globulin after an amniocentesis. The day following the procedure the client calls the nurse to report a temperature of 99.8° F (37.67°C). Which action should the nurse implement?
- A. Instruct the client to maintain bed rest for 24 hours.
- B. Encourage the client to increase her intake of oral fluids
- C. Schedule a visit with the healthcare provider today
- D. Verify the administered Rho(D) immune globulin's compatibility
Correct Answer: C
Rationale: A temperature elevation post-amniocentesis may indicate infection, requiring prompt evaluation by a healthcare provider.
A 16-year-old gravida 1, para 0 client has just been admitted to the hospital with a diagnosis of eclampsia. She is not presently convulsing Which intervention should the nurse plan to include in this client's nursing care plan?
- A. Monitor blood pressure pulse, and respirations every 4 hour
- B. Keep an airway at the bedside
- C. Allow liberal family visitation
- D. Assess temperature every hour
Correct Answer: B
Rationale: Eclampsia can lead to seizures, making airway management equipment critical to ensure safety during a potential seizure event.
What instruction is most important for the nurse to provide a client in the first trimester of pregnancy who is experiencing nausea?
- A. Avoid alcohol, caffeine, and smoking.
- B. Eliminate between meal snacks
- C. Practice relaxation techniques when the nausea first begins
- D. Increase intake of fluids to 3 quarts daily
Correct Answer: C
Rationale: Relaxation techniques like deep breathing can help manage nausea, especially if triggered by stress or anxiety, making it the most effective immediate intervention.
A woman at 36-weeks gestation who is Rh negative is admitted to labor and delivery reporting abdominal cramping. She is placed on strict bedrest and the fetal heart rate and contraction pattern are monitored with an external fetal monitor Two hours after admission, the nurse notes a large amount of bright red vaginal bleeding. Which nursing intervention has the highest priority?
- A. Determine fetal position by performing Leopold maneuvers.
- B. Assess the fetal heart rate and client's contraction pattern
- C. Confirm Rh and Coombs status for Rho(D) immunoglobulin administration
- D. Perform sterile vaginal examination to determine dilatation
Correct Answer: B
Rationale: Bright red vaginal bleeding is a critical sign that may indicate placental issues or fetal distress. Assessing the fetal heart rate and contraction pattern is the highest priority to ensure the well-being of both mother and baby.