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 monitoring a client in the second stage of labor. What finding indicates the client is ready to push?
- A. Membranes have ruptured.
- B. Cervix is completely dilated.
- C. Client reports back pain.
- D. Contractions are 10 minutes apart.
Correct Answer: B
Rationale: Complete cervical dilation marks the beginning of the second stage, signaling readiness to push.
A client with chronic kidney disease has arterial blood gas values being reviewed by a nurse. Which of the following sets of values should the nurse expect?
- A. pH 7.25, HCO3- 19 mEq/L, PaCO2 30 mm Hg
- B. pH 7.30, HCO3- 26 mEq/L, PaCO2 50 mm Hg
- C. pH 7.50, HCO3- 20 mEq/L, PaCO2 32 mm Hg
- D. pH 7.55, HCO3- 30 mEq/L, PaCO2 31 mm Hg
Correct Answer: A
Rationale: In chronic kidney disease, metabolic acidosis is common due to impaired kidney function leading to reduced bicarbonate excretion. The correct values indicating metabolic acidosis in this scenario are a low pH (acidosis), low bicarbonate (HCO3-) level, and low PaCO2 (compensation through respiratory alkalosis). Therefore, the expected values for a client with chronic kidney disease would be pH 7.25, HCO3- 19 mEq/L, PaCO2 30 mm Hg, as depicted in choice A.
A nurse is caring for an infant who has signs of neonatal abstinence syndrome. Which of the following actions should the nurse take?
- A. Provide a stimulating environment
- B. Monitor blood glucose level every hr.
- C. Initiate seizure precautions.
- D. Place the infants on his back with legs extended.
Correct Answer: C
Rationale: Neonatal abstinence syndrome (NAS) occurs in infants who are exposed to addictive substances in utero, typically opioids. The signs of NAS can include irritability, tremors, feeding difficulties, and seizures. Therefore, it is essential for the nurse to initiate seizure precautions when caring for an infant with signs of NAS. This includes ensuring a safe environment, padding the crib, monitoring closely for seizure activity, and having emergency medications readily available if needed. Providing a stimulative environment (Option A) would be inappropriate as it can exacerbate symptoms of NAS. While monitoring blood glucose (Option B) is important in some situations, such as for infants of diabetic mothers, it is not the priority in NAS. Placing the infant on their back with legs extended (Option D) does not directly address the immediate concerns related to NAS.
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 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.