Nokea
The nurse is caring for four antepartum clients. Which client should the nurse see first?
- A. Client with hyperemesis gravidarum who is currently vomiting (9%)
- B. Client with molar pregnancy who has dark brown vaginal discharge (8%)
- C. Client with suspected ectopic pregnancy who has abdominal and shoulder pain (71%)
- D. Client with threatened miscarriage who says, 'I am a Jehovah's Witness.' (10%)
Correct Answer: C
Rationale: A suspected ectopic pregnancy is a medical emergency due to the risk of rupture and internal bleeding, which can be life-threatening. Abdominal and shoulder pain are hallmark symptoms, indicating possible referred pain from diaphragmatic irritation. This client requires immediate assessment and intervention, prioritizing over hyperemesis gravidarum (which, while serious, is less immediately life-threatening), molar pregnancy (which needs monitoring but is not an acute emergency), and threatened miscarriage (which requires evaluation but is less urgent without active bleeding or pain).
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A client in labor with a history of a previous cesarean birth has chosen to attempt a vaginal birth. During labor, which finding would be most concerning to the nurse?
- A. Cessation of contractions and maternal tachycardia
- B. Fetal tachycardia with moderate variability
- C. Increased anxiety and discomfort with contractions
- D. Painful, strong contractions every 3-4 minutes
Correct Answer: A
Rationale: Cessation of contractions with maternal tachycardia (A) suggests uterine rupture, a life-threatening emergency in VBAC due to scar dehiscence. Fetal tachycardia (B) is concerning but less specific, anxiety (C) is expected, and regular contractions (D) are normal.
Which of these statements best describes the characteristic of an effective reward-feedback system?
- A. Specific feedback is given as close to the event as possible
- B. Staff are given feedback in equal amounts over time
- C. Positive statements precede a negative statement
- D. Performance goals should be higher than what is attainable
Correct Answer: A
Rationale: Feedback is most useful when given immediately. Positive behavior is strengthened through immediate feedback, and it is easier to modify problem behaviors if what constitutes appropriate behavior is clearly understood.
The nurse is caring for a client who is experiencing hypotension and respiratory depression after administration of IV midazolam. The nurse should anticipate that the client will receive
- A. Acetylcysteine
- B. Benztropine
- C. Phentolamine
- D. Flumazenil
Correct Answer: D
Rationale: Midazolam, a benzodiazepine, can cause respiratory depression and hypotension in overdose. Flumazenil (D) is the specific antidote, reversing benzodiazepine effects. Acetylcysteine (A) treats acetaminophen overdose, benztropine (B) manages extrapyramidal symptoms, and phentolamine (C) treats hypertensive crises, none of which apply here.
A 6-year-old child is receiving chemotherapy for leukemia. Which comment by the child indicates to the nurse that the child is adjusting well to the therapy?
- A. I am so tired. I want Mommy to hold me.'
- B. Look at my new hat. I wear it all the time. It's pretty.'
- C. See all my bruises. They are funny colors.'
- D. I wish I could eat pizza, but everything makes me throw up.'
Correct Answer: B
Rationale: Wearing a hat proudly suggests positive coping with hair loss from chemotherapy, indicating adjustment, unlike complaints of fatigue, bruising, or nausea.
The nurse is caring for a client who received albuterol 30 minutes ago for an acute exacerbation of asthma. It would indicate that the medication has been effective if the client experiences a decreased
- A. Use of accessory muscles
- B. Blood pressure
- C. Level of anxiety
- D. Heart rate
Correct Answer: A
Rationale: Albuterol, a bronchodilator, relieves bronchospasm in asthma, reducing airway resistance. Decreased use of accessory muscles (A) indicates improved breathing and oxygenation, a direct sign of albuterol's effectiveness. Changes in blood pressure (B), anxiety (C), or heart rate (D) are not primary indicators of albuterol's effect, as they may be influenced by other factors like the stress of the attack or concurrent medications.