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:
- Hematuria and Proteinuria 2+ are relevant findings that may indicate a potential worsening condition.
- Leukorrhea is unrelated to the diagnosis and should not be considered for interpretation.
- Positive clonus is a sign of potential improvement as it suggests a neurological response.
- BUN 40 mg/dL is a critical value that indicates potential renal impairment.
- Platelet count 110,000/mm3 is a concerning finding that suggests a potential worsening condition.
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A nurse is providing teaching to a client who is 2 days postpartum and wants to continue using her diaphragm for contraception. Which of the following instructions should the nurse include?
- A. You should have your provider refit you for a new diaphragm.'
- B. You should use an oil-based vaginal lubricant when inserting your diaphragm.'
- C. You should keep the diaphragm in place for at least 4 hours after intercourse.'
- D. You should store your diaphragm in sterile water after each use.'
Correct Answer: A
Rationale: Correct Answer: A. The nurse should instruct the client to have her provider refit her for a new diaphragm because the body undergoes changes postpartum, affecting the size and shape of the cervix and vaginal canal. A new fitting ensures proper size and fit for effective contraception.
B: Using oil-based vaginal lubricant can damage the diaphragm and increase the risk of breakage.
C: Keeping the diaphragm in place for a prolonged period increases the risk of toxic shock syndrome and infection, so it should be removed within 24 hours.
D: Storing the diaphragm in sterile water can lead to bacterial growth, increasing the risk of infection. It should be stored in a dry, cool place.
A nurse is assessing a newborn who has neonatal abstinence syndrome. Which of the following findings should the nurse expect?
- A. Diminished deep tendon reflexes
- B. Excessive crying
- C. Decreased muscle tone
- D. Absent Moro reflex
Correct Answer: B
Rationale: The correct answer is B: Excessive crying. Neonatal abstinence syndrome is characterized by withdrawal symptoms in newborns exposed to addictive substances in utero. Excessive crying is a common manifestation due to neurological irritability. Diminished deep tendon reflexes (A) would not be expected as the central nervous system is hyperactive. Decreased muscle tone (C) is unlikely as muscle rigidity or tremors are more common. Absent Moro reflex (D) is not typically seen as it is a primitive reflex present in newborns.
A nurse is assessing a client who is at 6 weeks of gestation and adheres to a vegan diet. Which of the following questions should the nurse ask to assess the client’s dietary intake?
- A. How much protein do you eat in a day?
- B. Are you taking a Vitamin C supplement?
- C. Have you considered eating shellfish?
- D. When was the last time you ate meat?
Correct Answer: A
Rationale: The correct answer is A: "How much protein do you eat in a day?" This question is important because a vegan diet may lack sufficient protein, crucial for fetal development at 6 weeks gestation. Protein is essential for cell growth and repair. Choice B is incorrect as Vitamin C is abundant in plant-based foods. Choice C is incorrect because shellfish are not part of a vegan diet. Choice D is incorrect because consuming meat contradicts a vegan diet.
Which of the following assessment findings requires Immediate follow-up? Select all that apply,
- A. Platelet count
- B. Vaginal bleeding
- C. HCT
- D. RBC Count
- E. Fetal heart rate
- F. hgb
- G. WBC Count
Correct Answer: B,C,E,F
Rationale: The correct answers are B, C, E, and F. Vaginal bleeding requires immediate follow-up to assess for potential complications. HCT, HGB, and WBC count are crucial for evaluating maternal health. Fetal heart rate is essential for monitoring fetal well-being. Platelet count and RBC count are important but not as urgent as the other findings.
A nurse is assessing a newborn following a forceps-assisted birth. Which of the following clinical manifestations should the nurse identify as a complication of this birth method?
- A. Polycythemia
- B. Hypoglycemia
- C. Bronchopulmonary dysplasia
- D. Facial palsy
Correct Answer: D
Rationale: The correct answer is D: Facial palsy. Forceps-assisted births can put pressure on the baby's face, leading to facial nerve injury and subsequent facial palsy. This can present as weakness or paralysis of facial muscles. Polycythemia (A) is not typically associated with forceps-assisted births. Hypoglycemia (B) is more commonly seen in infants of diabetic mothers or preterm infants. Bronchopulmonary dysplasia (C) is a lung condition often seen in premature infants on ventilatory support. The key is to recognize the specific complications related to forceps-assisted births, making choice D the most appropriate in this scenario.