Nokea
The nurse is reviewing the adolescent's medical record. Which of the following conditions is the client most likely developing? Complete the following sentence by using the list of options. The adolescent is most likely developing -------------------------- evidenced by --------------------------
- A. Pelvic inflammatory disease
- B. Ectopic pregnancy
- C. C-reactive protein
- D. Beta hCG level
- E. Urinalysis
Correct Answer:
Rationale: Correct Answer: A: Pelvic inflammatory disease
Rationale: Pelvic inflammatory disease (PID) is a common condition in adolescents due to sexually transmitted infections. The nurse reviewing the medical record indicates a focus on the reproductive system. Ectopic pregnancy and Beta hCG levels are related but not the most likely in this case. C-reactive protein and urinalysis are general tests not specific to PID.
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A nurse is caring for a postpartum client who is receiving heparin via a continuous IV infusion for thrombophlebitis in their left calf. Which of the following actions should the nurse take?
- A. Administer aspirin for pain.
- B. Maintain the client on bed rest.
- C. Massage the affected leg every 12 hr.
- D. Apply cold compresses to the affected calf.
Correct Answer: B
Rationale: The correct answer is B: Maintain the client on bed rest. In a client receiving heparin for thrombophlebitis, bed rest is essential to prevent dislodgment of the clot and avoid further complications. Moving around can increase the risk of embolism. Administering aspirin (choice A) is not recommended as it can increase the risk of bleeding with heparin. Massaging the affected leg (choice C) can dislodge the clot leading to embolism. Applying cold compresses (choice D) can also increase the risk of dislodging the clot. The key is to promote circulation without dislodging the clot, which is achieved by keeping the client on bed rest.
A nurse is assessing a newborn 12 hr after birth. Which of the following manifestations should the nurse report to the provider?
- A. Acrocyanosis.
- B. Transient strabismus.
- C. Jaundice.
- D. Caput succedaneum.
Correct Answer: C
Rationale: The correct answer is C: Jaundice. Jaundice in a newborn within the first 24 hours may indicate pathological conditions such as hemolytic disease or liver dysfunction. It requires immediate evaluation and treatment. Acrocyanosis (A) is a common finding in newborns due to immature circulation. Transient strabismus (B) is often seen in newborns and typically resolves on its own. Caput succedaneum (D) is swelling on the newborn's scalp from pressure during birth, which is a normal finding.
A nurse is teaching a client who has pregestational type 1 diabetes mellitus about management during pregnancy. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will need to increase my insulin doses during the first trimester.
- B. I should engage in moderate exercise for 30 minutes if my blood glucose is 250 or greater.
- C. I will continue taking my insulin if I experience nausea and vomiting.
- D. I will ensure that my bedtime snack is high in refined sugar.
Correct Answer: C
Rationale: The correct answer is C. Continuing to take insulin even if experiencing nausea and vomiting is crucial in managing blood glucose levels in type 1 diabetes during pregnancy. Nausea and vomiting can lead to decreased food intake, potentially causing hypoglycemia if insulin is not adjusted. Increasing insulin doses in the first trimester (choice A) is not recommended without healthcare provider guidance. Engaging in moderate exercise with high blood glucose (choice B) could worsen hyperglycemia. Ensuring a bedtime snack high in refined sugar (choice D) may lead to unstable blood glucose levels.
Which of the following findings should the nurse report to the provider?Select the 3 findings that should be reported.
- A. Uterine contractions
- B. Fetal heart rate
- C. Gestational age
- D. Vaginal examination
- E. Maternal blood pressure
Correct Answer: A,B,D
Rationale: The nurse should report uterine contractions (A) to monitor for preterm labor, fetal heart rate (B) to assess fetal well-being, and vaginal examination (D) to evaluate cervical changes. Gestational age (C) is typically known and doesn't require immediate reporting. Maternal blood pressure (E) is important but not a priority in this context.
A nurse is performing a routine assessment on a client who is at 18 weeks of gestation. Which of the following findings should the nurse expect?
- A. Deep tendon reflexes 4+.
- B. Fundal height 14 cm.
- C. Blood pressure 142/94 mm Hg.
- D. FHR 152/min.
Correct Answer: D
Rationale: The correct answer is D: FHR 152/min. At 18 weeks gestation, a normal fetal heart rate (FHR) ranges from 120-160/min. This is indicative of a healthy fetus. A: Deep tendon reflexes 4+ is not a typical finding during a routine assessment in pregnancy. B: Fundal height of 14 cm is more consistent with around 12-13 weeks gestation, not 18 weeks. C: Blood pressure of 142/94 mm Hg is elevated and may indicate hypertension, which is not expected at this stage of pregnancy.