Nokea
A 17-year-old client presents to the clinic with concerns that she has not begun menstruating. She states that she is a gymnast and has been competing since she was 9 years old. Based on this history, what does the nurse know the client is most likely experiencing?
- A. Secondary amenorrhea
- B. Polycystic ovary syndrome
- C. Primary amenorrhea
- D. Dysmenorrhea
Correct Answer: C
Rationale: The correct answer is C: Primary amenorrhea. A 17-year-old who has not started menstruating is experiencing primary amenorrhea. This is likely due to her intense physical activity as a gymnast, which can delay the onset of menstruation. Secondary amenorrhea (A) occurs when menstruation stops after it has already begun. Polycystic ovary syndrome (B) is characterized by hormonal imbalances and ovarian cysts, not delayed onset of menstruation. Dysmenorrhea (D) refers to painful menstruation, which is not the issue in this case.
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For HIV treatment, the pregnant woman should be expected to receive:
- A. Antibiotics
- B. Protease analogues
- C. Zidovudine
- D. Acyclovir
Correct Answer: C
Rationale: Rationale:
1. Zidovudine (AZT) is recommended for HIV-infected pregnant women to reduce the risk of vertical transmission to the baby.
2. It inhibits viral replication and decreases viral load in the mother, reducing transmission to the fetus.
3. Antibiotics are not effective for HIV treatment. Protease analogues are not typically used in pregnancy due to safety concerns. Acyclovir is used for herpes simplex virus, not HIV.
The nurse is caring for an Rh-negative mother on the postpartum unit. What scenario indicates the need to administer RhoGAM to this patient?
- A. She has had one Rh-negative child and is pregnant with an Rh-negative child.
- B. She has had an Rh-positive infant and is pregnant with an Rh-positive fetus.
- C. She has had an O-negative child and is pregnant with a B-negative child.
- D. She is a primipara with an O-negative child.
Correct Answer: B
Rationale: Rationale:
1. Rh-negative mother with Rh-positive infant: During delivery, fetal blood can mix with maternal blood leading to sensitization.
2. Sensitization can cause the mother's immune system to produce antibodies against Rh antigen.
3. RhoGAM is administered to prevent antibody formation in Rh-negative mothers carrying Rh-positive infants.
Summary:
- A: Incorrect. No risk of sensitization as both child and fetus are Rh-negative.
- B: Correct. Rh-negative mother with Rh-positive infant at risk for sensitization.
- C: Incorrect. Rh factor mismatch between children doesn't require RhoGAM.
- D: Incorrect. Being primipara or child's blood type doesn't warrant RhoGAM administration.
The nurse is providing education to parents of a child with cleft palate. What will the nurse instruct the parents to report immediately?
- A. Facial paralysis
- B. Ear infections
- C. Increasing intracranial pressure (ICP)
- D. Drooling
Correct Answer: B
Rationale: The correct answer is B: Ear infections. Parents of a child with a cleft palate should report ear infections immediately because children with cleft palate are at higher risk for developing ear infections due to issues with Eustachian tube function. Ear infections can lead to hearing loss if left untreated. Facial paralysis (A) is not directly related to cleft palate. Increasing ICP (C) is not typically associated with cleft palate. Drooling (D) is common in children with cleft palate and does not require immediate reporting unless there are other concerning symptoms present.
A nurse is teaching a community health class of women and explains that an STI is associated with an increased risk of infertility in women. Which STIs should the nurse identify?
- A. HSV-2
- B. Syphilis
- C. Chlamydia
- D. HPV
Correct Answer: C
Rationale: The correct answer is C: Chlamydia. Chlamydia is associated with an increased risk of infertility in women due to its ability to cause pelvic inflammatory disease (PID), which can lead to scarring and damage to the reproductive organs. This scarring can result in blocked fallopian tubes, making it difficult for an egg to be fertilized by sperm. HSV-2 (Choice A) is a viral infection that primarily causes genital herpes but is not directly linked to infertility. Syphilis (Choice B) can lead to serious complications but infertility is not a common outcome. HPV (Choice D) is a sexually transmitted infection that can cause genital warts and cervical cancer, but it does not typically lead to infertility in women.
The correct injection technique for infants of mothers who are known carriers of hepatitis B virus is to:
- A. Avoid all intramuscular injections until 1 month of age
- B. Dilute intramuscular injections with added normal saline
- C. Mix all injections that the infant will need in a single syringe
- D. Bathe the area where the infant will receive injections
Correct Answer: A
Rationale: The correct answer is A because infants born to mothers who are known carriers of hepatitis B virus should receive the hepatitis B vaccine within 12 hours of birth. Delaying intramuscular injections until 1 month of age increases the risk of vertical transmission of the virus. Choice B is incorrect because diluting injections with normal saline is unnecessary and may compromise the effectiveness of the vaccine. Choice C is incorrect as mixing all injections in a single syringe can lead to contamination and inaccurate dosing. Choice D is incorrect as bathing the injection site does not prevent vertical transmission of the virus.