Nokea
The nurse is assessing the client 30 min later. How should the nurse interpret the findings? For each finding, click to specify whether the finding is unrelated to the diagnosis, an indication of potential improvement, or an indication of potential worsening condition.
- A. Fundus at level of umbilicus
- B. Cloudy urine
- C. Blood pressure 80/50 mm Hg
- D. Moderate lochia rubra
- E. Thready pulse
- F. Fundus firm to palpation
Correct Answer:
Rationale: Correct Answer:
Rationale:
- Fundus at the level of the umbilicus is an indication of potential improvement as it indicates proper involution of the uterus.
- Cloudy urine is unrelated to the diagnosis and may indicate other issues like urinary tract infection.
- Blood pressure of 80/50 mm Hg is an indication of potential worsening condition as it is hypotensive.
- Moderate lochia rubra is also an indication of potential worsening condition as it may indicate excessive bleeding.
- Thready pulse is unrelated to the diagnosis.
- Fundus firm to palpation is an indication of potential improvement as it indicates proper uterine contraction and involution.
You may also like to solve these questions
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 have longer nails due to the extended intrauterine period. Large deposits of subcutaneous fat (A) are common in term and postterm newborns, not specific to postterm. Thin covering of fine hair on shoulders and back (B) is typical in preterm newborns, not postterm. Pale, translucent skin (D) is seen in preterm infants, not postterm. Therefore, the most appropriate finding to expect in a postterm newborn is nails extending over tips of fingers.
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 signs of potential worsening conditions that the nurse should interpret as concerning findings.
- Positive clonus is a sign of potential improvement, indicating a positive response to treatment.
- Leukorrhea is unrelated to the diagnosis and should not be a focus of interpretation after 24 hours.
- BUN 40 mg/dL and Platelet count 110,000/mm3 are not provided in the question and thus cannot be interpreted.
A nurse is reviewing laboratory findings for a client who is at 20 weeks of gestation. Which of the following findings should the nurse report to the provider?
- A. Hematocrit 37% (37% to 47%)
- B. Creatinine 0.9 mg/dL (0.5 to 1 mg/dL)
- C. WBC count 11,000/mm3 (5,000 to 10,000/mm3)
- D. Fasting blood glucose 180 mg/dL (74 to 106 mg/dL)
Correct Answer: D
Rationale: The correct answer is D: Fasting blood glucose 180 mg/dL (74 to 106 mg/dL). During pregnancy, elevated blood glucose levels can indicate gestational diabetes, which can pose risks to both the mother and the fetus. A fasting blood glucose level of 180 mg/dL is significantly above the normal range of 74 to 106 mg/dL and warrants immediate attention from the healthcare provider to initiate appropriate management and monitoring.
Choice A (Hematocrit 37%): Falls within the normal range for a pregnant woman and does not raise immediate concerns.
Choice B (Creatinine 0.9 mg/dL): Within the normal range and not typically a cause for concern at this level.
Choice C (WBC count 11,000/mm3): Slightly elevated but can be a normal physiological response to pregnancy due to increased blood volume and does not necessarily indicate a problem.
In summary, the other choices do not indicate an urgent issue requiring immediate provider notification
A nurse in a prenatal clinic is assessing a group of clients. Which of the following clients should the nurse see first?
- A. A client who is at 11 weeks of gestation and reports abdominal cramping
- B. A client who is at 15 weeks of gestation and reports tingling and numbness in right hand
- C. A client who is at 20 weeks of gestation and reports constipation for the past 4 days
- D. A client who is at 8 weeks of gestation and reports having three bloody noses in the past week
Correct Answer: A
Rationale: The correct answer is A: A client who is at 11 weeks of gestation and reports abdominal cramping. Abdominal cramping in early pregnancy can be a sign of ectopic pregnancy, miscarriage, or other complications requiring immediate attention. The nurse should see this client first to assess the situation and provide appropriate interventions.
Choice B is incorrect because tingling and numbness in the right hand is not typically an urgent issue in pregnancy. Choice C is incorrect as constipation, while uncomfortable, is not an immediate concern that requires urgent attention. Choice D is incorrect as bloody noses can be common in pregnancy due to increased blood volume and nasal congestion, but it does not require immediate attention unless severe or persistent.
A nurse manager on the labor and delivery unit is teaching a group of newly licensed nurses about maternal cytomegalovirus. Which of the following information should the nurse manager include in the teaching?
- A. Mothers will receive prophylactic treatment with acyclovir prior to delivery.
- B. Transmission can occur via the saliva and urine of the newborn.
- C. Lesions are visible on the mother’s genitalia.
- D. This infection requires that airborne precautions be initiated for the newborn.
Correct Answer: B
Rationale: The correct answer is B: Transmission can occur via the saliva and urine of the newborn. This is because cytomegalovirus (CMV) is commonly spread through bodily fluids like saliva, urine, and breast milk. It is important for the nurse manager to emphasize this point to the newly licensed nurses to highlight the potential routes of transmission.
Choice A is incorrect because acyclovir is not used for the treatment of CMV; it is used for herpes simplex virus infections. Choice C is incorrect because CMV typically does not present with visible lesions on the mother's genitalia. Choice D is incorrect because CMV is not transmitted through airborne routes, so airborne precautions are not necessary. It is important to focus on educating about the correct modes of transmission to prevent the spread of CMV.