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For which patient would an L/S ratio of 2:1 potentially be considered abnormal?
- A. A 38-year-old gravida 2, para 1, who is 38 weeks' gestation
- B. A 24-year-old gravida 1, para 0, who has diabetes
- C. A 44-year-old gravida 6, para 5, who is at term
- D. An 18-year-old gravida 1, para 0, who is in early labor at term
Correct Answer: B
Rationale: The correct answer is B. An L/S ratio of 2:1 is indicative of fetal lung maturity. This means that the lungs of the fetus are likely mature enough to function outside the womb. In choice B, the patient is 24 years old with diabetes, a condition that can affect fetal lung development, making it crucial to assess lung maturity.
Choice A is less likely to have abnormal lung maturity at 38 weeks' gestation. Choice C, a 44-year-old gravida 6, para 5, is more likely to have mature fetal lungs due to multiple pregnancies. Choice D, an 18-year-old in early labor at term, may not necessarily have abnormal lung maturity as she is at term and in labor.
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Which laboratory result would be a cause for concern if exhibited by a patient at her first prenatal visit during the second month of her pregnancy?
- A. Rubella titer, 1:6
- B. Platelets, 300,000/mm3
- C. White blood cell count, 6000/mm3
- D. Hematocrit 38%, hemoglobin 13 g/dL
Correct Answer: A
Rationale: The correct answer is A: Rubella titer, 1:6. A low rubella titer indicates susceptibility to rubella infection, which can be harmful during pregnancy. Rubella can lead to birth defects or miscarriage. Platelets, WBC count, and hematocrit/hemoglobin levels are within normal range and not typically concerning during the early stages of pregnancy.
A nurse has just inserted an orogastric gavage tube into a preterm baby. When would the nurse determine that the tube is in the proper location?
- A. When gastric aspirate is removed from the tube.
- B. When the baby suckles on the tubing.
- C. When respirations are unlabored during tube insertion.
- D. When the tubing can be inserted no farther.
Correct Answer: A
Rationale: The presence of gastric aspirate confirms that the tube is in the stomach, which is the proper location for feeding.
A client who had a vaginal delivery 2 hours earlier has just been transferred to the postpartum unit from labor and delivery. Which of the following nursing care goals is of highest priority?
- A. The client will breastfeed her baby every 2 hours.
- B. The client will consume a nutritious diet.
- C. The client will have a moderate lochial flow.
- D. The client will ambulate in the hallways every shift.
Correct Answer: C
Rationale: Ensuring the client has a moderate lochial flow is a priority to monitor for postpartum hemorrhage.
A nurse is reading a research study that states, 'There is a strong negative correlation between the independent and dependent variables (r = --0.85).' The nurse interprets the statement as which of the following?
- A. The dependent variable caused a change in the independent variable.
- B. The independent and dependent variables are significantly different.
- C. As values of the independent variable go up, values of the dependent variable go down.
- D. When the confidence interval is computed, the negative value will change to positive.
Correct Answer: C
Rationale: A negative correlation means that as one variable increases, the other decreases. The strength of the correlation is indicated by the absolute value of r.
During a postpartum examination, the nurse notes that a client’s left calf is warm and swollen. Which of the following actions by the nurse is appropriate at this time?
- A. Notify the client’s physician.
- B. Teach the client to massage her leg.
- C. Apply ice packs to the client’s leg.
- D. Encourage the client to ambulate.
Correct Answer: A
Rationale: A warm, swollen calf may indicate deep vein thrombosis (DVT), a serious condition requiring immediate medical attention.