Nokea
The nurse is caring for a term neonate who is diagnosed with patent ductus arteriosus. While performing a physical assessment of the neonate, the nurse anticipates that the neonate will exhibit which of the following?
- A. Decreased cardiac output with faint peripheral pulses.
- B. Profound cyanosis over most of the body.
- C. Loud cardiac murmurs through systole and diastole.
- D. Harsh systolic murmurs with a palpable thrill.
Correct Answer: C
Rationale: Patent ductus arteriosus typically causes a loud, continuous cardiac murmur heard through systole and diastole.
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A multigravid client is admitted to the hospital with a diagnosis of ectopic pregnancy. The nurse anticipates that, because the client's fallopian tube has not yet ruptured, which of the following may be ordered?
- A. Progestin contraceptives(Hylutin).
- B. Medroxyprogesterone(Depo-Provera).
- C. Methotrexate.
- D. Dyphylline(Dilor).
Correct Answer: C
Rationale: Methotrexate is used to treat unruptured ectopic pregnancies.
During the first hour after delivery, assessment of a multiparous client who delivered a neonate weighing 4,593 g (10 lb, 2 oz) by cesarean delivery reveals a soft fundus with excessive lochia rubra. The nurse should include which of the following in the client's plan of care?
- A. Administration of intravenous oxytocin.
- B. Placement of the client in a side-lying position.
- C. Rigorous fundal massage every 5 minutes.
- D. Preparation for an emergency hysteromyomectomy.
Correct Answer: A
Rationale: A soft fundus and excessive lochia suggest uterine atony, which is treated with oxytocin to promote uterine contraction.
A 16-year-old primigravid client, with a history of attending one prenatal visit, is admitted to the hospital in active labor at 37 weeks' gestation. Her cervix is 7 cm dilated with the presenting part at 0 station. She enters the labor unit appearing anxious and hyperventilating. Because of the hyperventilation, the nurse should assess the client for:
- A. Metabolic alkalosis.
- B. Metabolic acidosis.
- C. Respiratory alkalosis.
- D. Respiratory acidosis.
Correct Answer: C
Rationale: Hyperventilation causes excessive exhalation of carbon dioxide, leading to respiratory alkalosis (elevated blood pH). Metabolic imbalances are less likely, and respiratory acidosis occurs with hypoventilation.
A client is considering the hormonal IUD. Which of the following client statements indicates a need for further teaching?
- A. The IUD may reduce my menstrual bleeding.
- B. The IUD can stay in place for several years.
- C. The IUD will prevent ovulation every month.
- D. The IUD does not protect against STIs.
Correct Answer: C
Rationale: The hormonal IUD does not primarily prevent ovulation every month; it mainly thins the uterine lining and thickens cervical mucus. The other statements are correct, indicating a need for further teaching.
The physician orders an amnioinfusion for a primigravid client at term who is diagnosed with oligohydramnios. Which of the following should the nurse include in the client's teaching plan about the purpose of this procedure?
- A. To decrease the frequency and severity of variable decelerations.
- B. To minimize the possibility of fetal metabolic alkalosis.
- C. To increase the fetal heart rate accelerations during a contraction.
- D. To raise the amniotic fluid index to more than 15 cm.
Correct Answer: A
Rationale: Amnioinfusion replaces amniotic fluid in oligohydramnios, reducing cord compression and the frequency/severity of variable decelerations. It does not affect metabolic alkalosis, heart rate accelerations, or guarantee a specific fluid index.