Nokea
If the nurse documents all the following data, which finding should be reported immediately?
- A. Refusal to eat
- B. Complaint of nausea
- C. Absent bowel sounds
- D. Temperature of 101°F (38.3°C) orally
Correct Answer: C
Rationale: Absent bowel sounds may indicate peritonitis or bowel obstruction, serious complications of appendicitis requiring immediate reporting to prevent further deterioration.
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19 years old primigravida comes in emergency at 32 weeks of gestation. She is complaining of blurring of vision,gross edema. On examination her B.P is 170/115 mm Hg. What is the most likely diagnosis:
- A. Hypertension.
- B. Renal disease.
- C. Eclampsia.
- D. Preeclampsia.
- E. Thyroid disease.
Correct Answer: D
Rationale: Preeclampsia is characterized by hypertension (BP ≥140/90 mmHg) after 20 weeks gestation with symptoms like edema and visual disturbances. Eclampsia involves seizures which are not mentioned. Hypertension alone lacks other symptoms and renal or thyroid disease are less likely without specific indicators.
The nurse is caring for a 30-year-old,single female who delivered a term newborn. What is the best way for the nurse to assess the impact of the newborn on the client’s lifestyle?
- A. Observe how the client interacts with her hospital visitors.
- B. Review the prenatal record for clues about the client’s lifestyle.
- C. Ask the client what plans she has made for newborn care at home.
- D. Observe the relationship between the client and her newborn’s father.
Correct Answer: C
Rationale: Open-ended questions about newborn care plans encourage sharing of lifestyle adjustments especially for single parents. Visitors prenatal records or father involvement are less direct.
The full-term newborn is placed under phototherapy lights to treat hyperbilirubinemia. The nurse should assess the newborn for dehydration due to which effect of phototherapy?
- A. Decreases sodium absorption
- B. Increases absorption of bilirubin
- C. Decreases urinary output
- D. Increases insensible water loss
Correct Answer: D
Rationale: Phototherapy increases insensible water loss risking dehydration. It breaks down bilirubin for excretion not absorption and doesn’t directly affect sodium or urinary output.
The nurse is caring for the newborn infant. The nurse should prepare to assess the newborn’s anterior fontanel by which method?
- A. Lay the infant on his or her back.
- B. Stimulate the infant to cry strongly.
- C. Feel near the parietal and occipital bones.
- D. Place the infant in a sitting position.
Correct Answer: D
Rationale: The anterior fontanel is assessed with the infant in a sitting position (45°–90°) to evaluate size and abnormalities. Supine positioning or crying may cause bulging and parietal/occipital bones locate the posterior fontanel.
Cardiac output is highest in:
- A. 1st trimester.
- B. 2nd trimester.
- C. 3rd trimester.
- D. During labour.
- E. During delivery.
Correct Answer: E
Rationale: Cardiac output peaks during delivery due to increased demand from uterine contractions and maternal effort. It rises progressively during pregnancy but is highest at delivery.