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A nurse is caring for a client who is at 41 weeks of gestation and has a positive contraction stress test. For which of the following diagnostic tests should the nurse prepare the client?
- A. Percutaneous umbilical blood sampling.
- B. Amnioinfusion.
- C. Biophysical profile (BPP).
- D. Chorionic villus sampling (CVS).
Correct Answer: C
Rationale: The correct answer is C: Biophysical profile (BPP). At 41 weeks gestation with a positive contraction stress test, the client may be at risk for uteroplacental insufficiency. A BPP assesses fetal well-being by evaluating fetal movement, tone, breathing, amniotic fluid volume, and fetal heart rate reactivity. This test helps determine if the fetus is getting enough oxygen and nutrients. Preparing the client for a BPP is crucial in monitoring the fetal status and making decisions regarding further management.
Incorrect choices:
A: Percutaneous umbilical blood sampling is an invasive procedure used to evaluate fetal blood gases and acid-base status, typically performed when there are concerns about fetal well-being like severe growth restriction or Rh incompatibility.
B: Amnioinfusion is the infusion of fluid into the amniotic cavity and is used to correct oligohydramnios (low amniotic fluid volume).
D: Chorionic villus
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A nurse is caring for a postpartum client who is receiving heparin via a continuous IV infusion for thrombophlebitis in their left calf. Which of the following actions should the nurse take?
- A. Administer aspirin for pain.
- B. Maintain the client on bed rest.
- C. Massage the affected leg every 12 hr.
- D. Apply cold compresses to the affected calf.
Correct Answer: B
Rationale: The correct answer is B: Maintain the client on bed rest. In a client receiving heparin for thrombophlebitis, bed rest is essential to prevent dislodgment of the clot and avoid further complications. Moving around can increase the risk of embolism. Administering aspirin (choice A) is not recommended as it can increase the risk of bleeding with heparin. Massaging the affected leg (choice C) can dislodge the clot leading to embolism. Applying cold compresses (choice D) can also increase the risk of dislodging the clot. The key is to promote circulation without dislodging the clot, which is achieved by keeping the client on bed rest.
A nurse is assessing a newborn who was born at 26 weeks of gestation using the New Ballard Score. Which of the following findings should the nurse expect?
- A. Minimal arm recoil
- B. Popliteal angle of 90°
- C. Creases over the entire foot sole
- D. Raised areolas with 3 to 4 mm buds
Correct Answer: A
Rationale: The correct answer is A: Minimal arm recoil. In premature newborns born at 26 weeks of gestation, they typically exhibit minimal arm recoil due to their immature neuromuscular development. This is a key characteristic assessed in the New Ballard Score to determine the gestational age of the newborn. Choices B, C, and D are incorrect as they do not align with the expected findings in a premature newborn at 26 weeks of gestation. Popliteal angle of 90° (Choice B) is more typical in a term newborn. Creases over the entire foot sole (Choice C) are also more common in term newborns. Raised areolas with 3 to 4 mm buds (Choice D) are indicative of a more mature newborn and not typically seen in a premature newborn at 26 weeks of gestation.
For each assessment finding, click to specify if the finding is consistent with hypoglycemia, hyperbilirubinemia, or sepsis.
- A. Ecchymotic caput Succedaneum.
- B. Decreased temperature.
- C. Lethargy.
- D. Poor feeding.
- E. Respiratory distress.
- F. Yellow sclera and oral mucosa.
Correct Answer: B, C, D, E, F
Rationale: The correct answer is . Decreased temperature (B) can indicate hypoglycemia, sepsis, or hypothermia. Lethargy (C) can be a sign of hypoglycemia, sepsis, or other serious conditions. Poor feeding (D) is common in hypoglycemia, sepsis, and other illnesses. Respiratory distress (E) is a red flag for sepsis. Yellow sclera and oral mucosa (F) suggest hyperbilirubinemia. Ecchymotic caput Succedaneum (A) is not typically associated with these conditions.
A nurse is caring for a 1-month-old infant who has manifestations of severe dehydration and a prescription for parenteral fluid therapy. The guardian asks, 'What are the indications that my baby needs an IV?' Which of the following responses should the nurse make?
- A. Your baby needs an IV because she is not producing tears.
- B. Your baby needs an IV because her heart rate is decreased.
- C. Your baby needs an IV because she is breathing slower than normal.
- D. Your baby needs an IV because her fontanels are bulging.
Correct Answer: A
Rationale: The correct answer is A. Infants with severe dehydration may not produce tears due to lack of fluid. This indicates the need for IV fluid therapy to rehydrate the baby. Lack of tears is a sign of significant dehydration in infants.
Option B, decreased heart rate, is not a specific sign of dehydration in infants and not a direct indication for IV fluids. Option C, slow breathing, is also not a direct indication of dehydration, as infants may have varied respiratory rates for other reasons. Option D, bulging fontanels, can be a sign of increased intracranial pressure but is not a direct indication for IV fluids in this context.
Which of the following conditions should the nurse identify as being consistent with the adolescent's assessment findings? For each finding click to specify if the assessment findings are consistent with trichomoniasis, gonorrhea, or candidiasis. Each finding may support more than one disease process.
- A. Abdominal pain.
- B. Greenish discharge.
- C. Diabetes.
- D. Pain on urination.
- E. Absence of condom.
Correct Answer: B, D
Rationale: To determine the correct answer, we need to identify which assessment findings are consistent with trichomoniasis, gonorrhea, or candidiasis.
B: Greenish discharge is consistent with both trichomoniasis and gonorrhea due to their characteristic discharge color.
D: Pain on urination is a common symptom of gonorrhea, making it consistent with this condition.
Therefore, the correct answer is , as Greenish discharge and Pain on urination are consistent with gonorrhea. Abdominal pain and Diabetes are not specific to any of the mentioned conditions.