Nokea
The nurse is caring for a client who is 24-weeks gestation and reports increased thirst and urination. Which diagnostic test result should the nurse report to the healthcare provider?
- A. Hemoglobin A1C.
- B. Postprandial blood glucose test
- C. Fasting blood glucose
- D. Oral glucose tolerance test
Correct Answer: C
Rationale: Increased thirst and urination at 24 weeks suggest possible gestational diabetes. Fasting blood glucose is a standard initial screening test to detect abnormal glucose levels.
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The nurse is assessing a newborn who was precipitously delivered at 38-weeks gestation The newborn is tremulous, tachycardic, and hypertensive. Which assessment action is most important for the nurse to implement?
- A. Obtain a drug screen for cocaine
- B. Weigh and measure the newborn
- C. Determine reactivity of neonatal reflexes
- D. Perform gestational age assessment
Correct Answer: A
Rationale: Tremulousness, tachycardia, and hypertension in a newborn suggest possible drug exposure, such as cocaine, requiring an urgent drug screen to guide treatment.
Assessment findings of a 4-hour-old newborn include: axillary temperature of 96.8° F (35.8° C), heart rate of 150 beats/minute with a soft murmur, irregular respiratory rate at 64 breaths/minute, jitteriness, hypotonic and weak cry. Based on these findings, which action should the nurse implement?
- A. Document the findings in the record
- B. Obtain a heel stick blood glucose level.
- C. Place a pulse oximeter on the heel.
- D. Swaddle the infant in a warm blanket
Correct Answer: B
Rationale: Jitteriness, hypotonia, and a weak cry suggest possible hypoglycemia, a critical condition requiring immediate blood glucose testing.
The nurse examines a client who is admitted in active labor and determines the cervix is 3 cm dilated 50% effaced, and the presenting part is at 0 station. An hour later. she tells the nurse that she wants to go to the bathroom. Which action should the nurse implement first?
- A. Review the fetal heart rate pattern
- B. Check the pH of the vaginal fluid
- C. Determine cervical dilation.
- D. Palpate the client's bladder
Correct Answer: D
Rationale: A desire to use the bathroom may indicate a full bladder, which can impede labor progress. Palpating the bladder is the priority to assess this.
The nurse is caring for a client who delivered 6 hours ago. Assessment findings reveal a boggy uterus that is displaced above and to the right of the umbilicus. Which action should the nurse take?
- A. Encourage voiding
- B. Notify healthcare provider
- C. Inspect the perineal pad
- D. Monitor vital signs
Correct Answer: A
Rationale: A boggy uterus displaced above and to the right of the umbilicus often indicates a distended bladder, which can prevent proper uterine contraction. Encouraging voiding addresses this issue, helping the uterus return to its normal position and firm up.
A multiparous client with active herpes lesions is admitted to the unit with spontaneous rupture of membranes. Which action should the nurse take?
- A. Prepare for a cesarean section
- B. Cover the lesion with a dressing
- C. Obtain blood cultures
- D. Administer penicillin.
Correct Answer: A
Rationale: Active herpes lesions pose a risk of neonatal herpes transmission during vaginal delivery. Preparing for a cesarean section is the priority to minimize this risk.