Nokea
The clinic nurse prepares to assess a client who is in the second trimester of pregnancy. When measuring the fundal height, what should the nurse expect to note with this measurement regarding gestational age?
- A. It is less than gestational age.
- B. It correlates with gestational age.
- C. It is greater than gestational age.
- D. It has no correlation with gestational age.
Correct Answer: B
Rationale: Until the third trimester, the measurement of fundal height will, on average, correlate with the gestational age. Therefore, options 1, 3, and 4 are incorrect.
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The nurse instructs a mother of a child who had a plaster cast applied to the arm about measures that will help the cast dry. Which instructions should the nurse provide to the mother? Select all that apply.
- A. Lift the cast using the fingertips.
- B. Place the child on a firm mattress.
- C. Direct a fan toward the cast to facilitate drying.
- D. Support the cast and adjacent joints with pillows.
- E. Place the extremity with the cast in a dependent position.
- F. Reposition the extremity with the cast every 2 to 4 hours.
Correct Answer: B,C,D,F
Rationale: To help the cast dry, the child should be placed on a firm mattress. A fan may be directed toward the cast to facilitate drying. Once the cast is dry, the cast should sound hollow and be cool to touch. The cast and adjacent joints should be elevated and supported with pillows. To ensure thorough drying, the extremity with the cast should be repositioned every 2 to 4 hours. The cast is lifted by using the palms of the hands (not the fingertips) to prevent indentation in the wet cast surface. Indentations could possibly cause pressure on the skin under the cast.
The nurse performing a prenatal assessment on a client in the first trimester of pregnancy discovers that the client frequently consumes beverages containing alcohol. Why should the nurse initiate interventions immediately to assist the client in avoiding alcohol consumption?
- A. To reduce the potential for fetal growth restriction in utero
- B. To promote the normal psychosocial adaptation of the mother to pregnancy
- C. To minimize the potential for placental abruptions during the intrapartum period
- D. To reduce the risk of teratogenic effects to embryo's developing fetal organs and tissue
Correct Answer: D
Rationale: Alcohol consumption during the first trimester poses a significant risk for teratogenic effects, as this is a critical period for organogenesis in the developing embryo. Exposure to alcohol can lead to fetal alcohol syndrome or other congenital anomalies, making immediate intervention essential to protect fetal development. While fetal growth restriction, psychosocial adaptation, and placental abruption are concerns, they are less directly associated with early pregnancy alcohol exposure compared to teratogenic effects.
The nurse is reviewing the records of recently admitted clients to the postpartum unit. The nurse determines that which clients would have an increased risk for developing a puerperal infection? Select all that apply.
- A. A client with a history of previous infections
- B. A client who has given birth to a set of twins
- C. A client who had numerous vaginal examinations
- D. A client who has experienced three previous miscarriages
- E. A client who underwent a vaginal delivery of the newborn
- F. A client who experienced prolonged rupture of the membranes
Correct Answer: A,C,F
Rationale: Risk factors associated with puerperal infection include a history of previous infections, excessive number of vaginal examinations, cesarean births, prolonged rupture of the membranes, prolonged labor, trauma, and retained placental fragments. A vaginal delivery, a history of miscarriages, and the delivery of twins are not considered as risk factors for developing a puerperal infection.
A client receiving total parenteral nutrition (TPN) reports nausea, polydipsia, and polyuria. To determine the cause of the client's report, the nurse should assess which client data?
- A. Rectal temperature
- B. Last serum potassium
- C. Capillary blood glucose
- D. Serum blood urea nitrogen and creatinine
Correct Answer: C
Rationale: Clients receiving TPN are at risk for hyperglycemia related to the increased glucose load of the solution. The symptoms exhibited by the client are consistent with hyperglycemia. The nurse would need to assess the client's blood glucose level to verify these data. The other options would not provide any information that would correlate with the client's symptoms.
The newborn nursery nurse is performing an admission assessment on a newborn with the diagnosis of subdural hematoma. Which intervention should the nurse implement to assess for the primary symptom associated with subdural hematoma?
- A. Monitor the urine for blood.
- B. Monitor the urinary output pattern.
- C. Test for contractures of the extremities.
- D. Test for equality of extremity reflexes.
Correct Answer: D
Rationale: A subdural hematoma can cause pressure on a specific area of the cerebral tissue. This can cause changes in the stimuli responses in the extremities on the opposite side of the body, especially if the newborn is actively bleeding. Options 1 and 2 are incorrect. After delivery, a newborn would normally be incontinent of urine. Blood in the urine would indicate abdominal trauma and would not be a result of the hematoma. Option 3 is incorrect because contractures would not occur this soon after delivery.