Nokea
The nurse is caring for a client with a diagnosis of gestational hypertension. Which symptom is most characteristic?
- A. Hypertension
- B. Proteinuria
- C. Fetal macrosomia
- D. Painful vaginal bleeding
Correct Answer: A
Rationale: Hypertension (BP ≥140/90) is the defining symptom of gestational hypertension. Proteinuria indicates preeclampsia and fetal macrosomia or painful bleeding are unrelated.
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An 80-year-old widow is living with her son and daughter-in-law. The home health nurse has been making weekly visits to draw blood for a prothrombin time test. The client is taking 5 mg of coumadin per day. She appears more debilitated, and bruises are noted on her face. Elder abuse is suspected. Which of the following are signs of persons who are at risk for abusing an elderly person?
- A. A family member who is having marital problems and is regularly abusing alcohol
- B. A person with adequate communication and coping skills who is employed by the family
- C. A friend of the family who wants to help but is minimally competent
- D. A lifelong friend of the client who is often confused
Correct Answer: A
Rationale: This answer is correct. Two risk factors are identified in this answer. This answer is incorrect. Persons at risk tend to lack communication skills and effective coping patterns. This answer is incorrect. Persons at risk are usually family members or those reluctant to provide care. This answer is incorrect. This individual has a vested interest in providing care.
The nurse is teaching basic newborn care to a group of first-time parents. The nurse should explain that a sponge bath is recommended for the first two weeks of life because:
- A. New parents need time to learn how to hold the newborn.
- B. The umbilical cord needs time to separate.
- C. Newborn skin is easily traumatized by washing.
- D. The chance of chilling the newborn outweighs the benefits of bathing.
Correct Answer: B
Rationale: Sponge baths are recommended until the umbilical cord separates (typically within 1-2 weeks) to keep the cord dry and prevent infection. The other reasons are not the primary rationale for this practice.
Which of the following signs might indicate a complication during the labor process with vertex presentation?
- A. Fetal tachycardia to 170 bpm during a contraction
- B. Nausea and vomiting at 8-10 cm dilation
- C. Contraction lasting 60 seconds
- D. Appearance of dark-colored amniotic fluid
Correct Answer: D
Rationale: Fetal tachycardia may indicate fetal hypoxia; however, 170 bpm is only mild tachycardia. Nausea and vomiting occur frequently during transition and are not a complication. Contractions frequently last 60-90 seconds during the transitional phase of labor and are not considered a complication as long as the uterus relaxes completely between contractions. Passage of meconium in a vertex presentation is a sign of fetal distress; this may be normal in a breech presentation owing to pressure on the presenting part.
A male client has been an insulin-dependent diabetic for approximately 30 years. He frequently indulges in high-sugar foods and forgets to take his insulin. He has not experienced acute diabetic emergencies over the years but is now beginning to demonstrate symptoms of diabetic peripheral neuropathy. This distresses him because dancing is one of his favorite pastimes. He decides to question his wife's home health nurse about diabetic peripheral neuropathy. The nurse points out his noncompliance to his diabetic diet and insulin regimen. The client answers the nurse, 'It has been my experience that the diabetic diet is very difficult to follow. As far as the insulin, isn't a fellow allowed to forget now and then?' The client's actions and response best demonstrate:
- A. Depression
- B. Anger
- C. Denial
- D. Bargaining
Correct Answer: C
Rationale: Depression may be an underlying feature, but it is not evident from limited data presented here. Anger is not exhibited in his response. Denial is evident in the client's actions; through the years, he has had a casual approach to his illness. He only becomes concerned when bodily changes affect his present lifestyle, when in fact he should have been concerned all along. His verbal response also reflects denial. There is no evidence of bargaining in the client's actions or verbal response.
After performing a sterile vaginal exam on a client who has just been admitted to the unit in active labor and placed on an electronic fetal monitor, the RN assesses that the fetal head is at 21 station. She documents this on the monitor strip. Fetal head at 21 station means that the fetal head is located where in the pelvis?
- A. One centimeter below the ischial spines
- B. One centimeter above the ischial spines
- C. Has not entered the pelvic inlet yet
- D. Located in the pelvic outlet
Correct Answer: B
Rationale: Station refers to the relationship of the presenting part to the ischial spines. A station of -1 indicates the fetal head is 1 cm above the ischial spines.