Nokea
The client diagnosed with gestational diabetes delivered a 10-pound 5-ounce infant. Which is priority for the nursery nurse to monitor?
- A. Failure to latch on to the breast during feeding.
- B. Jaundice and clay-colored stools.
- C. Parchment-like skin and lack of lanugo.
- D. Low blood glucose readings.
Correct Answer: D
Rationale: Macrosomic infants from gestational diabetes are at risk for hypoglycemia; monitoring blood glucose is priority. Latching issues, jaundice, and skin changes are secondary.
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If this client is typical of others with this condition, she will most likely report to the nurse that she experiences urinary incontinence during which time?
- A. When sitting
- B. As she walks
- C. During sleep
- D. Upon sneezing
Correct Answer: D
Rationale: A cystocele causes stress incontinence, with urine leakage during activities that increase abdominal pressure, such as sneezing.
If the client experiences all of the following signs and symptoms after the laparoscopy, which one can the nurse attribute directly to the endoscopic procedure?
- A. Nausea and vomiting
- B. Shoulder discomfort
- C. Urinary frequency
- D. Leg cramps
Correct Answer: B
Rationale: Shoulder discomfort is a common post-laparoscopy symptom due to residual carbon dioxide gas irritating the diaphragm.
The client diagnosed with ovarian cancer is prescribed radiation therapy for regional control of the disease. Which statement indicates the client requires further teaching?
- A. I will not wash the marks off my abdomen.'
- B. I will have a treatment every day for six (6) weeks.'
- C. Nausea caused by radiation therapy cannot be controlled.'
- D. I need to drink a nutritional shake if I don’t feel like eating.'
Correct Answer: C
Rationale: Nausea from radiation can be managed with antiemetics; this statement indicates a misconception. Preserving marks, daily treatments, and nutritional shakes are correct.
The nurse enters the room of a 24-year-old client diagnosed with testicular cancer. The fiancée of the client asks the nurse, 'Will we be able to have children?' Which is the nurse’s best response?
- A. Your fiancée will be able to father children like always.'
- B. You will have to adopt children because he will be sterile.'
- C. You and he should consider sperm banking prior to treatment.'
- D. Have you discussed this with your fiancée? I can’t discuss this with you.'
Correct Answer: C
Rationale: Sperm banking is recommended before testicular cancer treatment (e.g., orchiectomy, chemotherapy) to preserve fertility. Normal fertility is unlikely, sterility is not guaranteed, and discussing with the fiancée avoids privacy issues but is less proactive.
The nurse is teaching a class on Breast Health Awareness. Which are the American Cancer Society’s recommended guidelines for the performance of breast self-examination (BSE)? List in order of recommended performance.
- A. Visualize the breast from the front while standing before a mirror.
- B. Gently squeeze the nipple to express any fluid.
- C. Turn to each side and view each breast in the mirror.
- D. Palpate each breast in a circular motion while lying on the back.
- E. Palpate each breast in a circular motion while in the shower.
Correct Answer: A,C,D,E,B
Rationale: ACS BSE steps: 1) Front mirror visualization; 2) Side visualization; 3) Lying palpation; 4) Shower palpation; 5) Nipple check for discharge.