Nokea
The client is admitted with a diagnosis of chorioamnionitis. Which symptom is most likely to be present?
- A. Maternal fever
- B. Fetal macrosomia
- C. Decreased uterine contractions
- D. Maternal hypotension
Correct Answer: A
Rationale: Chorioamnionitis an infection of the amniotic fluid and membranes typically causes maternal fever. Fetal macrosomia decreased contractions and hypotension are not primary symptoms.
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A female client presents to the obstetric-gynecology clinic for a pregnancy test, the result which turns out to be positive. Her last menstrual period began December 10, 1993. Using Nägele's rule, the nurse estimates her date of delivery to be:
- A. 17-Sep-94
- B. 10-Sep-94
- C. 3-Sep-94
- D. 17-Aug-94
Correct Answer: A
Rationale: According to Nägele's rule, the estimated date of delivery is calculated by adding 7 days to the date of the first day of the normal menstrual period (December 10 + 7 days = December 17), and then by counting back 3 months (December 17 - 3 mo = September 17). (B, C, D) These answers are incorrect.
The client is admitted with a diagnosis of gestational hypertension. Which assessment finding requires immediate notification of the physician?
- A. Blood pressure of 140/90
- B. 2+ proteinuria
- C. Headache and visual disturbances
- D. Edema of the hands
Correct Answer: C
Rationale: Headache and visual disturbances in gestational hypertension suggest severe preeclampsia or impending eclampsia requiring immediate physician notification. BP of 140/90 proteinuria and edema are concerning but less urgent unless severe.
The nurse is caring for a client with osteoporosis who is being discharged on alendronate (Fosamax). Which statement would indicate a need for further teaching?
- A. "I should take the medication immediately before bedtime every night."
- B. "I should remain in an upright position for 30 minutes after taking Fosamax."
- C. "The medication should be taken by mouth with water."
- D. "I should not have any food with this medication."
Correct Answer: A
Rationale: Alendronate should be taken in the morning on an empty stomach, not before bedtime (A), indicating a need for further teaching. Upright positioning (B), taking with water (C), and avoiding food (D) are correct.
A nurse is preparing to mix and administer chemotherapy. What equipment would be unnecessary to obtain?
- A. Surgical gloves
- B. Luer lok fitting IV tubing
- C. Surgical hat cover
- D. Disposable long-sleeve gown
Correct Answer: C
Rationale: Surgical gloves, Luer lok tubing, and long-sleeve gowns are essential for safe chemotherapy administration to prevent exposure. A surgical hat cover (C) is not typically required unless in a sterile procedure.
A client is placed in five-point restraints after exhibiting sudden violence after illegal drug use, and haloperidol (Haldol) 5 mg IM is administered. After 1 hour, his behavior is more subdued, but he tells the nurse, 'The devil followed me into this room, I see him standing in the corner with a big knife. When you leave the room, he's going to cut out my heart.' The nurse's best response is:
- A. I know you're feeling frightened right now, but I want you to know that I don't see anyone in the corner.'
- B. You'll probably see strange things for a while until the PCP wears off.'
- C. Try to sleep. When you wake up, the devil will be gone.'
- D. You're probably feeling guilty because you used illegal drugs tonight.'
Correct Answer: A
Rationale: The nurse is the client's link to reality. This response validates the authenticity of the client's experience by casting doubt on his belief and reinforcing reality.