Nokea
On the third postpartum day, the nurse would expect the lochia to be:
- A. Rubra
- B. Serosa
- C. Alba
- D. Scant
Correct Answer: A
Rationale: This discharge occurs from delivery through the 3rd day. There is dark red blood, placental debris, and clots. This discharge occurs from days 4-10. The lochia is brownish, serous, and thin. This discharge occurs from day 10 through the 6th week. The lochia is yellowish white. This is not a classification of lochia but relates to the amount of discharge.
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The client is admitted with a possible myocardial infarction. The nurse would anticipate an order from the physician for which laboratory test?
- A. Creatine kinase
- B. Ammonia
- C. Myoglobin
- D. Troponin T
- E. Gamma-glutamyl transferase
- F. Bilirubin
Correct Answer: A, C, D
Rationale: Creatine kinase (A), myoglobin (C), and troponin T (D) are cardiac biomarkers elevated in myocardial infarction. Ammonia (B), gamma-glutamyl transferase (E), and bilirubin (F) are unrelated to acute cardiac events.
The nurse is caring for a client hospitalized with nephrotic syndrome. Based on the client's treatment, the nurse should:
- A. Limit the number of visitors.
- B. Provide a low-protein diet.
- C. Discuss the possibility of dialysis.
- D. Offer the client additional fluids.
Correct Answer: D
Rationale: Nephrotic syndrome causes edema due to protein loss, requiring fluid management. Offering additional fluids is inappropriate unless prescribed, as it may worsen edema. Visitors, diet, and dialysis depend on specific orders.
A 19-year-old primigravida is admitted to the labor and delivery suite of the hospital. Her husband is accompanying her. The couple tells the nurse that this is the first hospital admission for her. The client's vaginal exam indicates she is 3 cm dilated, 80% effaced, and at -0 station. Based on the vaginal exam, she is in:
- A. Stage 2, latent phase
- B. Stage 1, active phase
- C. Stage 3, transition phase
- D. Stage 1, latent phase
Correct Answer: D
Rationale: The second stage of labor is from full cervical dilation through birth of the baby. The three phases of this stage include latency or resting, descent, and final transition. The client is less than fully dilated so she is not in stage 2. The first stage of labor begins with regular uterine contractions and continues until the woman is 10 cm dilated. The three phases of this stage include the early or latent phase (0-3 cm), the active phase (4-7 cm), and the transitional phase (7-10 cm). The client is <4 cm dilated so she is in the latent phase of the first stage of labor. The third stage of labor is from the birth of the baby until the delivery of the placenta. The client is less than fully dilated. The first stage of labor begins with regular uterine contractions and continues until the woman is 10 cm dilated. The three phases of this stage include the early or latent phase (0-3 cm), the active phase (4-7 cm), and the transitional phase (7-10 cm). The client is <4 cm dilated so she is in the latent phase of the first stage of labor.
A 25-year-old client believes she may be pregnant with her first child. She schedules an obstetric examination with the nurse practitioner to determine the status of her possible pregnancy. Her last menstrual period began May 20, and her estimated date of confinement using Nägele's rule is:
- A. 27-Mar
- B. 1-Feb
- C. 27-Feb
- D. 3-Jan
Correct Answer: C
Rationale: March 27 is a miscalculation. February 1 is a miscalculation. February 27 is the correct answer. To calculate the estimated date of confinement using Nagele's rule, subtract 3 months from the date that the last menstrual cycle began and then add 7 days to the result. January 3 is a miscalculation.
A client has been admitted to the nursing unit with the diagnosis of severe anemia. She is slightly short of breath, has episodes of dizziness, and complains her heart sometimes feels like it will 'beat out of her chest.' The physician has ordered her to receive 2 U of packed red blood cells. The most important nursing action to be taken is:
- A. Starting an 18-gauge IV infusion
- B. Having the consent form on the chart
- C. Administering the correct blood product to the correct client
- D. Transfusing the blood in a 2-hour time frame
Correct Answer: C
Rationale: An 18-gauge IV is an appropriate size for administering blood; however, client safety demands that the right blood product must be administered. The consent form is legally necessary to be on the chart, but client safety is maintained by giving the correct blood component to the correct client. Administering the correct blood product to the correct client will maintain physiological safety and minimize transfusion reactions. The blood administration should take place over the ordered time frame designated by the physician.