Nokea
The client at 34 weeks gestation is admitted with a diagnosis of preterm premature rupture of membranes (PPROM). The nurse should monitor for which complication?
- A. Chorioamnionitis
- B. Preterm delivery
- C. Fetal distress
- D. All of the above
Correct Answer: D
Rationale: PPROM increases the risk of chorioamnionitis (infection) preterm delivery (due to loss of amniotic fluid) and fetal distress (from infection or cord compression). All are potential complications requiring monitoring.
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A 44-year-old client had an emergency cholecystectomy 3 days ago for a ruptured gallbladder. She complains of severe abdominal pain. Assessment reveals abdominal rigidity and distention, increased temperature, and tachycardia. Diagnostic testing reveals an elevated WBC count. The nurse suspects that the client has developed:
- A. Gastritis
- B. Evisceration
- C. Peritonitis
- D. Pulmonary embolism
Correct Answer: C
Rationale: Assessment findings for gastritis would reveal anorexia, nausea and vomiting, epigastric fullness and tenderness, and discomfort. Evisceration is the extrusion of abdominal viscera as a result of trauma or sutures failing in a surgical incision. Peritonitis, inflammation of the peritoneum, can occur when an abdominal organ, such as the gallbladder, perforates and leaks blood and fluid into the abdominal cavity. This causes infection and irritation. Assessment findings of pulmonary embolism would reveal severe substernal chest pain, tachycardia, tachypnea, shortness of breath, anxiety or panic, and wheezing and coughing often accompanied by blood-tinged sputum.
The best size cathlon for administration of a blood transfusion to a six-year-old is:
- A. 18 gauge
- B. 19 gauge
- C. 22 gauge
- D. 20 gauge
Correct Answer: D
Rationale: A 20-gauge catheter is appropriate for blood transfusions in a six-year-old balancing adequate flow rate and minimal vessel trauma. Smaller gauges (22) may be too small and larger gauges (18 19) are more invasive than necessary.
A 27-year-old healthy primigravida is brought to the labor and birthing room by her husband at 32 weeks' gestation. She experienced a sudden onset of painless vaginal bleeding. Following an ultrasound examination, the diagnosis of bleeding secondary to complete placenta previa is made. Expected assessment findings concerning the abdomen would include:
- A. A rigid, boardlike abdomen
- B. Uterine atony
- C. A soft relaxed abdomen
- D. Hypertonicity of the uterus
Correct Answer: C
Rationale: A rigid, boardlike abdomen is an assessment finding indicative of placenta abruptio. A cause of postbirth hemorrhage is uterine atony. With placenta previa, uterine tone is within normal range. The placenta is located directly over the cervical os in complete previa. Blood will escape through the os, resulting in the uterus and abdomen remaining soft and relaxed. In placenta abruptio, hypertonicity of the uterus is caused by the entrapment of blood between the placenta and uterine wall, a retroplacental bleed. This does not exist in placenta previa.
A client is being treated for congestive heart failure. His medical regimen consists of digoxin (Lanoxin) 0.25 mg po daily and furosemide 20 mg po bid. Which laboratory test should the nurse monitor?
- A. Intake and output
- B. Calcium
- C. Potassium
- D. Magnesium
Correct Answer: C
Rationale: Furosemide is a nonpotassium-sparing loop diuretic. Hypokalemia is a common side effect of furosemide and may enhance digoxin toxicity.
The nurse is caring for a client in labor. The fetal heart rate is 80 bpm with moderate variability. The most appropriate initial action by the nurse is to:
- A. Notify the physician
- B. Administer oxygen at 8-10 liters per minute
- C. Reposition the client to her left side
- D. Increase the IV fluid rate
Correct Answer: C
Rationale: A fetal heart rate of 80 bpm indicates bradycardia possibly due to cord compression or uteroplacental insufficiency. Repositioning the client to her left side improves placental perfusion and is the first action. Oxygen notifying the physician or increasing fluids are secondary.