Nokea
The membranes of a multigravid client in active labor rupture spontaneously, revealing greenish colored amniotic fluid. The nurse interprets this finding as related to which of the following?
- A. Passage of meconium by the fetus.
- B. Maternal intrauterine infection.
- C. Rh incompatibility between mother and fetus.
- D. Maternal sexually transmitted disease.
Correct Answer: A
Rationale: Greenish amniotic fluid indicates meconium passage, often due to fetal stress.
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You are the nurse in an ambulatory surgical center. Which of the following risk factors are associated with impaired and delayed healing?
- A. A lack of zinc
- B. A lack of vitamin E
- C. High iron levels
- D. High phosphorus levels
Correct Answer: A
Rationale: Zinc deficiency impairs wound healing by affecting collagen synthesis and immune function.
Which of the following characteristics should the nurse include in the teaching plan for a multiparous client after delivering a neonate diagnosed with trisomy 13?
- A. Webbed neck
- B. Small testes
- C. Congenital heart defects
- D. Polydactyly
Correct Answer: C
Rationale: Trisomy 13 is commonly associated with congenital heart defects. Webbed neck is more typical of Turner syndrome, and small testes or polydactyly are less specific to trisomy 13.
A client with a history of atrial fibrillation is admitted with a heart rate of 160 beats per minute. The nurse should prioritize which of the following interventions?
- A. Administer diltiazem as prescribed.
- B. Obtain a 12-lead ECG.
- C. Administer aspirin.
- D. Apply oxygen via nasal cannula.
Correct Answer: A
Rationale: Diltiazem, a calcium channel blocker, is prioritized to control rapid heart rate in atrial fibrillation.
When assessing speech development, which of the following children should the nurse refer for further examination?
- A. A 4-month-old who laughs out loud.
- B. A 10-month-old who says 'dada' and 'mama.'
- C. A 1-year-old who says 3 to 5 words.
- D. An 18-month-old who only says 'no.'
Correct Answer: D
Rationale: An 18-month-old should have a vocabulary of about 15-20 words and start forming simple phrases. Only saying 'no' indicates a potential delay, warranting further evaluation. The other options reflect age-appropriate speech milestones.
A client with a history of type 2 diabetes mellitus is prescribed sitagliptin (Januvia). The nurse should monitor the client for which of the following side effects?
- A. Hypoglycemia.
- B. Pancreatitis.
- C. Hypertension.
- D. Weight gain.
Correct Answer: B
Rationale: Sitagliptin can cause pancreatitis, a serious side effect requiring monitoring for symptoms like abdominal pain.