Nokea
The nurse is assessing a client with a suspected diagnosis of abruptio placentae. Which finding is most indicative of this condition?
- A. Soft abdomen.
- B. Uterine tenderness and rigidity.
- C. Bright red, painless vaginal bleeding.
- D. Decreased fetal movements.
Correct Answer: B
Rationale: The correct answer is B: Uterine tenderness and rigidity. This finding is most indicative of abruptio placentae, which is the premature separation of the placenta from the uterine wall. Uterine tenderness and rigidity are classic signs due to the internal bleeding and blood accumulating between the placenta and uterine wall. This results in a tense and tender uterus.
A: Soft abdomen is incorrect as abruptio placentae typically presents with a firm, board-like abdomen due to uterine rigidity.
C: Bright red, painless vaginal bleeding is incorrect as abruptio placentae typically presents with dark red, painful vaginal bleeding.
D: Decreased fetal movements are incorrect as fetal distress can occur with abruptio placentae, but uterine tenderness and rigidity are more specific indicators of this condition.
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A couple comes in for an infertility workup, having attempted to get pregnant for 2 years. The woman, 37, has always had irregular menstrual cycles but is otherwise healthy. The man has fathered two children from a previous marriage and had a vasectomy reversal 2 years ago. The man has had two normal semen analyses, but the sperm seem to be clumped together. What additional test is needed?
- A. FSH level
- B. Antisperm antibodies
- C. Testicular biopsy
- D. Test of testicular infection
Correct Answer: B
Rationale: The correct answer is B: Antisperm antibodies. In this case, the man's history of vasectomy reversal and normal semen analyses with clumped sperm suggest a possible presence of antisperm antibodies. These antibodies can cause sperm agglutination, affecting fertility. Testing for antisperm antibodies can provide valuable information on potential immune-related infertility issues.
A: FSH level is not the most appropriate test in this scenario as the man's semen analyses were normal, indicating potential issues with sperm-egg interaction rather than hormonal imbalances.
C: Testicular biopsy is invasive and not necessary at this stage when the issue seems to be related to sperm clumping rather than a structural problem within the testes.
D: Test of testicular infection is unlikely as the man's semen analyses were normal, and there are no indications of infection based on the information provided.
The nurse is assessing a client with hyperemesis gravidarum. What lab finding is most concerning?
- A. Elevated hematocrit.
- B. Decreased potassium.
- C. Increased white blood cell count.
- D. Low fasting blood glucose.
Correct Answer: B
Rationale: The correct answer is B: Decreased potassium. In hyperemesis gravidarum, excessive vomiting can lead to electrolyte imbalances, particularly hypokalemia. Potassium plays a crucial role in nerve and muscle function, so a low potassium level can result in serious complications such as cardiac arrhythmias. Elevated hematocrit (A) may indicate dehydration, but it is not as immediately concerning as potassium imbalance. Increased white blood cell count (C) may suggest infection but is not directly related to hyperemesis gravidarum. Low fasting blood glucose (D) can occur due to inadequate nutrient intake but is not the most concerning finding in this case.
The nurse is caring for a client at 34 weeks' gestation with suspected preterm labor. What is the priority nursing action?
- A. Administer corticosteroids as prescribed.
- B. Encourage ambulation to relieve contractions.
- C. Provide the client with a high-protein snack.
- D. Monitor maternal blood pressure.
Correct Answer: A
Rationale: The correct answer is A: Administer corticosteroids as prescribed. Administering corticosteroids helps accelerate fetal lung maturity and reduce the risk of respiratory distress syndrome in preterm infants. It is the priority action in suspected preterm labor at 34 weeks' gestation.
Explanation for why other choices are incorrect:
B: Encouraging ambulation may not be safe in preterm labor as it can increase the risk of delivering the baby prematurely.
C: Providing a high-protein snack is not the priority action in suspected preterm labor.
D: Monitoring maternal blood pressure is important, but not the priority in this situation where the focus is on preventing complications for the preterm infant.
In a 28-day menstrual cycle, when does ovulation typically occur?
- A. around day 7
- B. around day 14
- C. around day 21
- D. around day 28
Correct Answer: B
Rationale: The correct answer is B: around day 14. Ovulation typically occurs around day 14 in a 28-day menstrual cycle. This is because ovulation usually happens around 14 days before the start of the next menstrual period. This timing aligns with the midpoint of the menstrual cycle, which is around day 14. Ovulation is the release of an egg from the ovary, marking the most fertile period for conception. Choices A, C, and D are incorrect because ovulation does not typically occur on day 7, day 21, or day 28 in a 28-day menstrual cycle.
The nurse is caring for a client in labor with a history of cesarean delivery. What is a priority assessment?
- A. Assess for signs of uterine rupture.
- B. Monitor maternal temperature hourly.
- C. Check for signs of preeclampsia.
- D. Assess for excessive fetal movement.
Correct Answer: A
Rationale: The correct answer is A: Assess for signs of uterine rupture. This is the priority assessment because a history of cesarean delivery puts the client at higher risk for uterine rupture during labor. Signs of uterine rupture include severe abdominal pain, abnormal fetal heart rate patterns, and vaginal bleeding. Early detection and intervention are crucial for the safety of both the mother and the baby. Monitoring maternal temperature (B) is important but not as critical as assessing for uterine rupture. Checking for signs of preeclampsia (C) is also important but not a priority in this specific scenario. Assessing for excessive fetal movement (D) is not a priority assessment in this case.