Nokea
The client is admitted to the unit with a diagnosis of abruptio placenta. Which finding is most significant when assessing this client?
- A. Bright red vaginal bleeding
- B. Abdominal pain and rigidity
- C. Alteration in the fetal heart tones
- D. A soft,boggy uterus
Correct Answer: C
Rationale: Abruptio placenta involves placental separation which can compromise fetal oxygenation leading to abnormal fetal heart tones (e.g. bradycardia or late decelerations). This is the most significant finding as it indicates fetal distress. Bleeding pain and rigidity are relevant but secondary to fetal well-being.
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Provide the 1-minute Apgar score for an infant born with the following findings: Heart rate: Above 100 Respiratory effort: Slow, irregular Muscle tone: Some flexion of extremities Reflex irritability: Vigorous cry Color: Body pink, blue extremities
- A. 7
- B. 10
- C. 8
- D. 9
Correct Answer: A
Rationale: Seven out of a possible perfect score of 10 is correct. Two points are given for heart rate above 100; 1 point is given for slow, irregular respiratory effort; 1 point is given for some flexion of extremities in assessing muscle tone; 2 points are given for vigorous cry in assessing reflex irritability; 1 point is assessed for color when the body is pink with blue extremities (acrocyanosis). For a perfect Apgar score of 10, the infant would have a heart rate over 100 but would also have a good cry, active motion, and be completely pink. For an Apgar score of 8 the respiratory rate, muscle tone, or color would need to fall into the 2-point rather than the 1-point category. For this infant to receive an Apgar score of 9, four of the areas evaluated would need ratings of 2 points and one area, a rating of 1 point.
The nurse would assess the client's correct understanding of the fertility awareness methods that enhance conception, if the client stated that:
- A. My sexual partner and I should have intercourse when my cervical mucosa is thick and cloudy.'
- B. At ovulation, my basal body temperature should rise about 0.5F.'
- C. I should douche immediately after intercourse.'
- D. My sexual partner and I should have sexual intercourse on day 14 of my cycle regardless of the length of the cycle.'
Correct Answer: B
Rationale: A slight rise in basal body temperature (about 0.5°F) after ovulation, due to progesterone, indicates correct understanding of fertility awareness.
A client returned to the unit following a pneumonectomy. As the nurse is assessing her incision, she notices fresh blood on the dressing. The nurse should first:
- A. Reinforce the dressing.
- B. Continue to monitor the dressing.
- C. Notify the physician.
- D. Note the time and amount of blood.
Correct Answer: C
Rationale: The physician should be notified immediately, because if the bleeding persists, the client may have to be taken back to surgery. Blood on the dressing is unusual and requires prompt action to assess and manage potential complications.
The nurse is caring for a client with a history of a pulmonary embolism who is receiving Lovenox (enoxaparin). The nurse should monitor the client for:
- A. Bleeding
- B. Hypertension
- C. Tachypnea
- D. Fever
Correct Answer: A
Rationale: Enoxaparin, a low-molecular-weight heparin, increases bleeding risk, requiring monitoring for signs like bruising or hematuria. Hypertension, tachypnea, and fever are not primary concerns.
A client with a history of a seizure disorder is receiving Phenobarbital. The nurse should teach the client to:
- A. Avoid alcohol
- B. Take the medication with meals
- C. Increase calcium intake
- D. Monitor for weight gain
Correct Answer: A
Rationale: Alcohol can interact with phenobarbital, increasing sedation or reducing seizure control. Meals, calcium, and weight gain are not primary concerns.