Nokea
The client is admitted at 32 weeks gestation with a diagnosis of gestational hypertension. Which assessment finding is most significant?
- A. Proteinuria of 2+
- B. Blood pressure of 140/90
- C. Edema of the hands and face
- D. Weight gain of 2 pounds per week
Correct Answer: A
Rationale: Proteinuria of 2+ is a significant finding in gestational hypertension as it suggests progression to preeclampsia which can lead to severe complications. BP of 140/90 edema and weight gain are concerning but less specific without proteinuria.
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An amniocentesis at 32 weeks gestation reveals that a multigravida with diabetes has an L/S ratio of 1:1 with the presence of phosphatidylglycerol. Based on the amniocentesis,the nurse knows that if delivered now:
- A. The newborn is at low risk for congenital anomalies.
- B. The newborn is at high risk for intrauterine growth retardation.
- C. The newborn is at high risk for respiratory distress syndrome.
- D. The newborn is at high risk for birth trauma.
Correct Answer: C
Rationale: An L/S ratio of 1:1 at 32 weeks indicates immature fetal lungs increasing the risk of respiratory distress syndrome (RDS) if delivered now. Phosphatidylglycerol presence is positive but does not fully mitigate RDS risk. The other risks are not directly related to the L/S ratio.
A client with a history of breast cancer is receiving tamoxifen (Nolvadex). Which adverse effect should the nurse monitor for?
- A. Weight loss
- B. Endometrial hyperplasia
- C. Hypotension
- D. Hair loss
Correct Answer: B
Rationale: Tamoxifen increases the risk of endometrial hyperplasia, a serious adverse effect due to its estrogenic effects on the uterus. Weight loss (A), hypotension (C), and hair loss (D) are not typical.
The nurse is caring for a client with a history of diverticulitis. Which meal selection indicates that the client understands the dietary teaching?
- A. Roast beef, mashed potatoes, and spinach
- B. Baked chicken, rice, and an apple
- C. Ham sandwich, chips, and whole wheat bread
- D. Spaghetti with meat sauce and garlic bread
Correct Answer: B
Rationale: Clients with diverticulitis should follow a low-residue diet during flare-ups to reduce bowel irritation. Baked chicken, rice, and an apple are low in fiber and suitable. The other options contain high-fiber or irritating foods (e.g., spinach, whole wheat, garlic).
Following a gastric resection, which of the following actions would the nurse reinforce with the client in order to alleviate the distress from dumping syndrome?
- A. Eating three large meals a day
- B. Drinking small amounts of liquids with meals
- C. Taking a long walk after meals
- D. Eating a low-carbohydrate diet
Correct Answer: D
Rationale: A low-carbohydrate diet prevents a hypertonic bolus, reducing dumping syndrome. The other options exacerbate the condition.
Diagnostic assessment findings for an infant with possible coarctation of the aorta would include:
- A. A third heart sound
- B. A diastolic murmur
- C. Pulse pressure difference between the upper extremities
- D. Diminished or absent femoral pulses
Correct Answer: D
Rationale: S1 and S2 in an infant with coarctation of the aorta are usually normal. S3 and S4 do not exist with this diagnosis. Either no murmur will be heard or a systolic murmur from an associated cardiac defect will be heard along the left upper sternal border. A diastolic murmur is not associated with coarctation of the aorta. Pulse pressure differences of >20 mm Hg exist between the upper extremities and the lower extremities. It is important to evaluate the upper and lower extremities with the appropriate-sized cuffs. Femoral and pedal pulses will be diminished or absent in infants with coarctation of the aorta.