Nokea
The nurse is collecting data from a client during the first routine prenatal examination. According to the last menstrual period, the estimated gestational age is 12 weeks. The nurse would expect to palpate the uterine fundus
- A. 12 cm above the umbilicus
- B. at the level of the umbilicus
- C. just below the xiphoid process
- D. just above the symphysis pubis
Correct Answer: D
Rationale: At 12 weeks, the uterine fundus is just above the symphysis pubis (D). It reaches the umbilicus at 20 weeks and higher levels later in pregnancy.
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When giving an intramuscular injection to an infant. Which of the following sites is preferred?
- A. Ventrogluteal region
- B. Deltoid
- C. Vastus lateralis
- D. Dorsogluteal region
Correct Answer: C
Rationale: Vastus lateralis is the ideal choice for infants.
The nurse is caring for a 3-month-old infant who has bacterial meningitis. Which of the following clinical findings support this diagnosis? Select all that apply.
- A. Depressed anterior fontanelle
- B. High-pitched cry
- C. Poor feeding
- D. Presence of the Babinski sign
- E. Vomiting
Correct Answer: B, C, E
Rationale: High-pitched cry (B), poor feeding (C), and vomiting (E) are signs of bacterial meningitis in infants. A depressed fontanelle (A) suggests dehydration, not meningitis, and Babinski sign (D) is normal in infants.
The nurse is monitoring a client who is in active labor with a cervical dilation of 6 cm. Which finding requires intervention by the nurse?
- A. Contraction duration of 95 seconds
- B. Contraction frequency of every 3 minutes
- C. Contraction intensity of 45 mm Hg
- D. Uterine resting tone of 10 mm Hg
Correct Answer: A
Rationale: Contraction duration of 95 seconds (A) is too long and may reduce fetal oxygenation, requiring intervention. Frequency (B), intensity (C), and resting tone (D) are within normal limits.
The nurse helps the health care provider perform a thoracentesis at the bedside. In which position does the nurse place the client to facilitate needle insertion and promote comfort?
- A. Fetal position, lying on unaffected side with knees drawn to the abdomen and hands clasped around them
- B. Lying on the affected side with head of the bed elevated to 30-45 degrees
- C. Prone with head turned to the affected side and arms over the head, supported by a pillow
- D. Upright leaning forward over the bedside table, with arms supported on pillows
Correct Answer: D
Rationale: Upright leaning forward (D) facilitates lung expansion and fluid access while ensuring comfort. Other positions (A, B, C) are less effective or uncomfortable.
The nurse is caring for a client who has congestive heart failure. Which finding indicates that her condition is getting worse?
- A. An increase in urine output
- B. A decrease in blood pressure
- C. A decrease in heart rate
- D. Warm, moist skin
Correct Answer: B
Rationale: A decrease in blood pressure suggests worsening cardiac output in congestive heart failure, indicating decompensation.