Nokea
For each body system below, specify the potential manifestations that the client may experience. Match each body system with the potential manifestation.
- A. Nausea
- B. Pain
- C. Headache
- D. Body aches
Correct Answer: D
Rationale: General: Body aches (D) - reflects systemic discomfort. Head, ears, eyes, nose, and throat: Headache (C) - common neurological symptom. Gastrointestinal: Nausea (A) - due to digestive disturbances. Breast: Pain (B) - related to tissue sensitivity or engorgement.
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A nurse is providing teaching about newborn safety to a client who is being admitted for induction of labor. Which of the following client statements indicates an understanding of the teaching?
- A. I will check the identification badge of anyone who removes my baby from our room.
- B. I should include a photo of my baby in any public birth announcements to social media.
- C. I will allow my baby to sleep on the bed in my room when I am in the shower.
- D. I should expect the nurses to carry my baby in their arms to the nursery.
Correct Answer: A
Rationale: Checking the identification badge ensures the individual removing the baby is authorized, reducing the risk of abduction. This is a recommended safety practice in hospital settings to protect newborns.
A nurse is caring for a client who is in labor and has a diagnosis of group B streptococcus B-hemolytic infection. Which of the following medications should the nurse plan to administer?
- A. Ampicillin.
- B. Azithromycin.
- C. Ceftriaxone.
- D. Acyclovir.
Correct Answer: A
Rationale: Ampicillin is a first-line antibiotic effective against group B streptococcus B-hemolytic bacteria, preventing neonatal infection during labor. It targets the bacterial cell wall synthesis and is safe in pregnancy.
A nurse conducts a physical exam of a client who reports feeling well. Which finding requires clinical intervention?
- A. No acute distress.
- B. No murmur or rub.
- C. Bilateral breath sounds clear.
- D. Fundal height 38 cm.
- E. Purulent cervical discharge.
Correct Answer: E
Rationale: Purulent cervical discharge suggests an ongoing infection, likely bacterial cervicitis. It reflects leukocyte accumulation due to pathogenic invasion, requiring clinical intervention to prevent complications.
A nurse is providing dietary teaching to a client who is at 29 weeks of gestation and has phenylketonuria. Which of the following food suggestions should the nurse include?
- A. Peanut butter sandwich.
- B. Sliced apples.
- C. Glass of skim milk.
- D. Scrambled egg.
Correct Answer: B
Rationale: Apples are low in phenylalanine, making them a safe option for individuals with phenylketonuria. They provide essential nutrients without contributing to phenylalanine accumulation.
A nurse is teaching a pregnant client who is Rh-negative about Rho(D) immune globulin. Which of the following statements by the client indicates an understanding of the teaching?
- A. This shot may be given after birth to protect future pregnancies.
- B. If my partner is Rh-negative, I will not receive the shot.
- C. I will receive the shot after delivery if my baby is Rh-negative.
- D. I should not receive any immunizations for 3 months after the shot.
Correct Answer: A
Rationale: Rho(D) immune globulin administered postpartum prevents maternal sensitization to Rh-positive fetal blood cells, reducing risks of hemolytic disease in subsequent pregnancies by suppressing maternal immune response.