Nokea
The nurse is preparing a woman in labor for an amniotomy. Which priority data should the nurse assess before the procedure?
- A. Fetal heart rate
- B. Maternal heart rate
- C. Fetal scalp sampling
- D. Maternal blood pressure
Correct Answer: A
Rationale: Fetal well-being must be confirmed before and after amniotomy. Fetal heart rate should be checked by Doppler or with the application of the external fetal monitor. Although maternal vital signs may be assessed, fetal heart rate is the priority. A fetal scalp sampling cannot be done when the membranes are intact.
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On assessment of the client diagnosed with stage III Lyme disease, which clinical manifestation should the nurse expect to note?
- A. Palpitations
- B. A cardiac dysrhythmia
- C. A generalized skin rash
- D. Enlarged and inflamed joints
Correct Answer: D
Rationale: Stage III Lyme disease develops within a month to several months after initial infection. It is characterized by arthritic symptoms such as arthralgia and enlarged or inflamed joints, which can persist for several years after the initial infection. A rash occurs during stage I, and cardiac and neurological dysfunction occur during stage II.
A client is scheduled for an arteriogram using a radiopaque dye. What is the most important information the nurse should determine before the procedure to assure the client's safety?
- A. Vital signs
- B. Intake and output
- C. Height and weight
- D. Allergy to iodine or shellfish
Correct Answer: D
Rationale: Allergy to iodine or seafood is associated with allergy to the radiopaque dye that is used for medical imaging examinations. Informed consent is necessary because an arteriogram requires the injection of a radiopaque dye into the blood vessel. Although the remaining options are components of the preprocedure assessment, the risks of allergic reaction and possible anaphylaxis are the most critical to the client's safety.
A client prescribed dextroamphetamine reports to the nurse difficulty falling asleep at night. The nurse instructs the client on how to minimize sleep disorders. Which statement by the client indicates that teaching has been effective?
- A. I'll take the medication with a bedtime snack.
- B. I'll take the medication upon awaking in the morning.
- C. I'll take the medication two hours before going to bed.
- D. I'll take the medication at least 6 hours before bedtime.
Correct Answer: D
Rationale: Dextroamphetamine is a central nervous system (CNS) stimulant that acts by releasing norepinephrine from the nerve endings. The client should take the medication at least 6 hours before going to bed at night to prevent disturbances with sleep. Therefore, the remaining options are incorrect.
A client at 35 weeks of gestation reports a sudden discharge of fluid from the vagina. Based on the data provided, which condition should the nurse suspect?
- A. Miscarriage
- B. Preterm labor
- C. Intrauterine fetal demise
- D. Premature rupture of the membranes
Correct Answer: D
Rationale: Premature rupture of the membranes is usually manifested by a sudden discharge of fluid from the vagina before 37 weeks of gestation. Miscarriage is typically manifested by vaginal bleeding and abdominal pain. Preterm labor is typically manifested by uterine contractions, cramping, and pressure before 37 weeks of gestation. Intrauterine fetal demise is usually manifested by an absence of fetal movements and heartbeat.
A pregnant client diagnosed with diabetes mellitus arrives at the primary health care clinic for a follow-up visit. What best assessment should the nurse perform to assess insulin function?
- A. Urine for specific gravity
- B. For the presence of edema
- C. Urine for glucose and ketones
- D. Blood pressure, pulse, and respirations
Correct Answer: C
Rationale: In a pregnant client with diabetes mellitus, assessing insulin function is critical to ensure glycemic control and prevent complications. Testing urine for glucose and ketones is the best assessment, as it directly indicates whether insulin is effectively managing blood glucose levels (glucose in urine suggests hyperglycemia) and whether the client is at risk for ketoacidosis (ketones indicate fat metabolism due to insufficient insulin). Urine specific gravity reflects hydration status, not insulin function. Edema assessment is relevant for preeclampsia or fluid overload, not insulin function. Vital signs like blood pressure, pulse, and respirations provide general health information but are not specific to insulin function.