Nokea
The nurse is assessing the client 24 hr later. How should the nurse interpret the findings?
- A. Hematuria
- B. Proteinuria 2+
- C. Leukorrhea
- D. Positive clonus
- E. BUN 40 mg/dL
- F. Platelet count 110,000/mm3
Correct Answer:
Rationale: Correct Answer:
Rationale: The correct interpretation is Hematuria. Hematuria (blood in urine) can be a sign of potential worsening condition, requiring further investigation. Proteinuria 2+, Leukorrhea, Positive clonus, BUN of 40 mg/dL, and Platelet count of 110,000/mm3 are not specifically related to the findings 24 hours later and do not provide direct information on the client's status. Hematuria should be a significant focus for further assessment.
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A nurse is assessing a newborn who was born postterm. Which of the following findings should the nurse expect?
- A. Large deposits of subcutaneous fat
- B. Thin covering of fine hair on shoulders and back
- C. Nails extending over tips of fingers
- D. Pale, translucent skin
Correct Answer: C
Rationale: The correct answer is C: Nails extending over tips of fingers. Postterm newborns tend to have longer nails due to the prolonged gestation period. This is because the nails continue to grow during the extra time in the womb. Large deposits of subcutaneous fat (A) are more common in preterm infants. Thin covering of fine hair on shoulders and back (B) is characteristic of lanugo, which is typically shed before birth. Pale, translucent skin (D) is more commonly seen in premature babies.
A nurse is assisting the provider to administer a dinoprostone insert to induce labor for a client. Which of the following actions should the nurse take?
- A. Allow the medication to reach room temperature prior to administration.
- B. Place the client in a semi-Fowler’s position for 1 hr after administration.
- C. Instruct the client to avoid urinary elimination until after administration.
- D. Verify that informed consent is obtained prior to administration.
Correct Answer: D
Rationale: The correct answer is D: Verify that informed consent is obtained prior to administration. This step is crucial to ensure the client understands the risks and benefits of the procedure. It promotes client autonomy and helps prevent legal issues.
A: Allowing the medication to reach room temperature is not a necessary step for administering dinoprostone insert.
B: Placing the client in a semi-Fowler's position is not indicated after administering dinoprostone insert.
C: Instructing the client to avoid urinary elimination is not necessary and could be harmful to the client.
E, F, G: No other options are provided, but they would likely be incorrect as well.
A nurse is planning care immediately following birth for a newborn who has a myelomeningocele that is leaking cerebrospinal fluid. Which of the following actions should the nurse include in the plan of care?
- A. Administer broad-spectrum antibiotics.
- B. Monitor the rectal temperature every 4 hr.
- C. Cleanse the site with povidone-iodine.
- D. Prepare for surgical closure after 72 hr.
Correct Answer: A
Rationale: The correct answer is A: Administer broad-spectrum antibiotics. This is crucial for preventing infection due to the leakage of cerebrospinal fluid, which can lead to meningitis. Antibiotics will help reduce the risk of infection until surgical repair can be done. Monitoring rectal temperature (B) is not directly related to addressing the myelomeningocele. Cleansing the site with povidone-iodine (C) may further irritate the area. Surgical closure (D) should not be delayed, as infection risk is high.
A nurse is caring for a client who is at 20 weeks of gestation and has trichomoniasis. Which of the following findings should the nurse expect?
- A. Thick, white vaginal discharge
- B. Urinary frequency
- C. Vulva lesions
- D. Malodorous discharge
Correct Answer: D
Rationale: The correct answer is D: Malodorous discharge. Trichomoniasis is a sexually transmitted infection caused by a parasite, leading to a characteristic foul-smelling vaginal discharge. This discharge is typically greenish-yellow, frothy, and may be accompanied by itching or irritation. Thick, white discharge (choice A) is more indicative of a yeast infection. Urinary frequency (choice B) is not a common symptom of trichomoniasis. Vulva lesions (choice C) are more likely to be seen in other infections or conditions. Therefore, the malodorous discharge is the most specific finding associated with trichomoniasis at 20 weeks of gestation.
A nurse is caring for an infant who has signs of neonatal abstinence syndrome. Which of the following actions should the nurse take?
- A. Monitor blood glucose level every hr.
- B. Place the infant on his back with legs extended.
- C. Initiate seizure precautions.
- D. Provide a stimulating environment.
Correct Answer: C
Rationale: The correct answer is C: Initiate seizure precautions. Neonatal abstinence syndrome can result in neurological symptoms, including seizures. Initiating seizure precautions involves ensuring a safe environment, padding the crib, and closely monitoring the infant for any signs of seizure activity. Monitoring blood glucose every hour (A) is not typically indicated for neonatal abstinence syndrome. Placing the infant on his back with legs extended (B) is a standard safe sleep practice but is not specific to managing neonatal abstinence syndrome. Providing a stimulating environment (D) can exacerbate symptoms of withdrawal and should be avoided.