Nokea
The nurse is assessing a postpartum client who delivered 2 hours ago. What finding requires immediate action?
- A. Fundus firm and midline.
- B. Lochia rubra with small clots.
- C. Boggy fundus above the umbilicus.
- D. Client reports perineal discomfort.
Correct Answer: C
Rationale: A boggy fundus indicates uterine atony, increasing the risk of hemorrhage.
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Which sexually transmitted infection is characterized by multiple soft warts on the perineum and rectal areas?
- A. Human papillomavirus (HPV).
- B. Human immunodeficiency virus (HIV).
- C. Syphilis.
- D. Trichomoniasis.
Correct Answer: A
Rationale: HPV can cause genital warts, which appear as soft warts in the genital area.
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.
A pregnant woman is to undergo an invasive procedure to evaluate the status of her fetus. To ensure informed consent, which action would be the priority responsibility of the nurse providing care to this woman?
- A. Asking relevant questions to determine the client's understanding
- B. Providing a detailed description of the risks and benefits of the procedure
- C. Explaining the exact steps that will occur during the procedure
- D. Offering suggestions for alternative options for treatment
Correct Answer: A
Rationale: The nurse's responsibilities related to informed consent include: Ensuring the consent form is completed with signatures from the client; serving as a witness to the signature process; and determining whether the client understands what she is signing by asking her pertinent questions.
A new mother asks the nurse why newborns receive an injection of vit. K after delivery. What will be the best response from the nurse?
- A. Newborns are given vit K to help with the digestion to help them absorb fat soluble vitamins
- B. Newborns are given vit K and erythromycin ointment to help prevent ophthalmia neonatorum
- C. Newborns lack the intestinal flora needed to produce vit K, so it is given to prevent bleeding episodes
- D. This vitamin substitutes for vitamin C and newborns will strengthen their immune system
Correct Answer: C
Rationale: Vitamin K is essential for clotting and prevents hemorrhagic disease.
A nurse is teaching a prenatal class regarding false labor. Which of the following information should the nurse include?
- A. "Your contraction will become more intense when walking"
- B. "You will have dilation and effacement of the cervix"
- C. You will have bloody show"
- D. "Your contraction will become temporally regular"
Correct Answer: D
Rationale: False labor, also known as Braxton Hicks contractions, are contractions that are irregular and do not lead to cervical dilation and effacement, unlike true labor contractions. During false labor, contractions may feel intense when walking, but they do not become progressively more intense over time, as is seen in true labor. Additionally, false labor contractions do not typically result in bloody show, which is a sign of impending true labor. Therefore, the correct information to include regarding false labor is that contractions will remain temporarily irregular in nature.