Nokea
The client is admitted with a diagnosis of vasa previa. Which delivery method is most likely to be planned?
- A. Vaginal delivery
- B. Cesarean section
- C. Forceps-assisted delivery
- D. Vacuum-assisted delivery
Correct Answer: B
Rationale: Vasa previa with fetal vessels crossing the cervical os requires cesarean section to prevent vessel rupture and fetal exsanguination during vaginal delivery. Forceps or vacuum delivery increases risk.
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The nurse is performing discharge teaching to a client who is on isoniazid (INH). Which diet selection by the client indicates to the nurse that further instruction is needed?
- A. Tuna casserole
- B. Ham salad sandwich
- C. Baked potato
- D. Broiled beef roast
Correct Answer: A
Rationale: Isoniazid has MAOI properties, requiring avoidance of tyramine-rich foods like tuna to prevent hypertensive crisis. Tuna casserole (A) indicates a need for further teaching. Ham salad (B) may have tyramine but is less definitive. Baked potato (C) and beef roast (D) are safe.
The nurse is assessing a client who had a colon resection two days ago. The client states, "I feel like my stitches have burst loose." Upon further assessment, dehiscence of the wound is noted. Which action should the nurse take?
- A. Immediately place the client in the prone position.
- B. Apply a sterile, saline-moistened dressing to the wound.
- C. Administer atropine to decrease abdominal secretions.
- D. Wrap the abdomen with an ACE bandage.
Correct Answer: B
Rationale: Applying a sterile, saline-moistened dressing protects the dehisced wound and prevents infection. Prone positioning (A) is inappropriate, atropine (C) doesn’t address dehiscence, and an ACE bandage (D) may worsen the condition.
The client is admitted with a diagnosis of preterm labor. Which symptom is most characteristic?
- A. Uterine contractions
- B. Fetal macrosomia
- C. Maternal fever
- D. Painless vaginal bleeding
Correct Answer: A
Rationale: Uterine contractions (regular frequent) are the hallmark of preterm labor occurring before 37 weeks. Fetal macrosomia maternal fever and painless bleeding are not characteristic.
The child with seizure disorder is being treated with phenytoin (Dilantin). Which of the following statements by the patient's mother indicates to the nurse that the patient is experiencing a side effect of Dilantin therapy?
- A. She is very irritable lately.'
- B. She sleeps quite a bit of the time.'
- C. Her gums look too big for her teeth.'
- D. She has gained about 10 pounds in the last six months.'
Correct Answer: C
Rationale: Gingival hyperplasia (overgrown gums) is a common side effect of phenytoin (Dilantin). Irritability, excessive sleep, and weight gain are not typical side effects of this medication.
Which nursing assessment indicates that involutional changes have occurred in a client who is three days postpartum?
- A. The fundus is firm and three finger widths below the umbilicus.
- B. The client has a moderate amount of lochia serosa.
- C. The fundus is firm and even with the umbilicus.
- D. The uterus is approximately the size of a small grapefruit.
Correct Answer: A
Rationale: A firm fundus three finger widths below the umbilicus by day three postpartum indicates normal uterine involution, as the uterus contracts and descends.