Nokea
The nurse is assessing a client with hyperemesis gravidarum. What finding requires immediate intervention?
- A. Urine output of 50 mL/hr.
- B. Weight loss of 5 pounds in 2 weeks.
- C. Dry mucous membranes and poor skin turgor.
- D. Nausea relieved by eating crackers.
Correct Answer: C
Rationale: Dehydration, indicated by dry mucous membranes and poor skin turgor, requires immediate intervention in hyperemesis gravidarum.
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The nurse should anticipate the labor pattern for a fetal occiput posterior position to be
- A. Prolonged and more painful
- B. Precipitous
- C. Rapid during transition
- D. Shorter than average during the latent phase
Correct Answer: A
Rationale: The nurse should anticipate the labor pattern for a fetal occiput posterior position to be prolonged and more painful. This is because in occiput posterior position, the baby's head is facing the mother's abdomen instead of her back, which can lead to slower descent and dilation of the cervix. The baby's head may have difficulty rotating to the optimal position for birth, causing longer labor and increased back pain for the mother. Nurses should be prepared to provide additional support and pain management strategies for women experiencing labor with a fetal occiput posterior position.
Before discharge, what health teaching should the nurse provide to a woman diagnosed with pelvic inflammatory disease (PID)?
- A. Endometriosis.
- B. Menopause.
- C. Ovarian hyperstimulation.
- D. Sexually transmitted infections.
Correct Answer: D
Rationale: PID is often caused by untreated STIs, so education about STIs is crucial.
What is the LNG-IUC mechanism of action?
- A. disruption of fertilization of the egg and sperm
- B. termination of a pregnancy
- C. creation of a hostile uterine environment
- D. thickening cervical mucus, atrophic endometrium
Correct Answer: D
Rationale: The LNG-IUC, or levonorgestrel-releasing intrauterine system, works primarily by thickening the cervical mucus, which inhibits the passage of sperm through the cervix. This mechanism reduces the likelihood of fertilization occurring. Additionally, LNG-IUC also causes atrophic changes in the endometrium, which makes it less conducive for implantation of a fertilized egg, further decreasing the chance of pregnancy.
During the assessment of a newborn, it is most important for the nurse to report a:
- A. Temperature of 97.7 degrees Fahrenheit
- B. Pale pink, rust-colored stain in the diaper
- C. Heart rate that drops to 120 beats/min
- D. Breathing pattern that is diaphragmatic with sternal retractions
Correct Answer: D
Rationale: Sternal retractions indicate respiratory difficulty.
Which should be included in teaching regarding treatment for pubic lice?
- A. The antibiotics should be taken for a full 10 days.
- B. All clothing should be pretreated with bleach before wearing.
- C. Shampoo should be applied for at least 2 hours before rinsing.
- D. The pubic hair should be combed after shampoo is removed.
Correct Answer: D
Rationale: Combing removes lice and nits after treatment.