Nokea
The nurse is assessing a client with suspected ectopic pregnancy. What is the most common symptom?
- A. Bright red vaginal bleeding.
- B. Severe lower abdominal pain.
- C. Increased fetal movement.
- D. Painless vaginal spotting.
Correct Answer: B
Rationale: Severe lower abdominal pain, often on one side, is a hallmark symptom of ectopic pregnancy.
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The nurse is caring for a pregnant client with a diagnosis of gestational diabetes. What finding indicates the need for immediate intervention?
- A. Blood sugar of 130 mg/dL after a meal.
- B. Fasting blood sugar of 95 mg/dL.
- C. Presence of ketones in the urine.
- D. Client reports increased thirst.
Correct Answer: C
Rationale: Ketones in the urine indicate poor glucose control and possible ketoacidosis, requiring urgent medical attention.
The physician has determined the need for forceps. The nurse should explain to the patient that the need for forceps is indicated because
- A. Premature placental separation (also used for prolapsed cord and nonreasoning fetal HR)
- B. Her support person is exhausted
- C. To shorten the first stage of labor
- D. To prevent fetal distress
Correct Answer: A
Rationale: Forceps delivery is indicated in situations where there is fetal distress due to premature placental separation or nonreassuring fetal heart rate. Forceps are used to facilitate a quicker delivery and reduce the risk to the baby during such emergency situations. Forces are also used in cases of fetal distress due to a prolapsed cord where a quick delivery is necessary to relieve pressure on the umbilical cord.
When reviewing the arterial blood gas values for a client, a nurse notes a pH of 7.32, PaCO2 of 48 mm Hg, and HCO3 of 23 mEq/L. What does this indicate about the acid-base balance?
- A. Respiratory acidosis
- B. Respiratory alkalosis
- C. Metabolic acidosis
- D. Metabolic alkalosis
Correct Answer: A
Rationale: The given values suggest respiratory acidosis. In respiratory acidosis, the pH is low (<7.35), PaCO2 is high (>45 mm Hg), and the HCO3 is normal or slightly elevated. In this scenario, the low pH (7.32) and high PaCO2 (48 mm Hg) indicate respiratory acidosis, where there is an excess of carbon dioxide in the blood, leading to acidification of the body fluids.
The nurse is monitoring a client with severe preeclampsia. What assessment finding indicates worsening condition?
- A. Proteinuria of +1.
- B. Respiratory rate of 16 breaths per minute.
- C. New-onset confusion and restlessness.
- D. Urine output of 40 mL/hr.
Correct Answer: C
Rationale: New-onset confusion and restlessness may indicate cerebral edema or impending eclampsia.
Which newborn reflex is assessed by stroking the cheek?
- A. Startle reflex
- B. Rooting reflex
- C. Babinski reflex
- D. Sucking reflex
Correct Answer: B
Rationale: The rooting reflex is observed when stroking the cheek, helping the newborn find the breast for feeding.