Nokea
The nurse understands vitamin k is for?
- A. Not initially synthesized because of sterile bowel at birth (so they don't have enough clothing factors)
- B. Necessary for the production of platelets
- C. Important for production red blood cells
- D. Responsible for the breakdown of bilirubin and the prevention of jaundice
Correct Answer: D
Rationale: The correct answer is D because vitamin K is responsible for the breakdown of bilirubin in the liver, which helps prevent jaundice in newborns. Bilirubin is a product of the breakdown of old red blood cells, and vitamin K plays a crucial role in this process. Choice A is incorrect as sterile bowel does not affect vitamin K synthesis. Choice B is incorrect because platelet production is not directly related to vitamin K. Choice C is incorrect as red blood cell production is mainly regulated by other nutrients like iron, vitamin B12, and folate, not vitamin K.
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Which client teaching instruction is necessary for a pregnant client who is to undergo a glucose challenge test (GCT) as part of a routine pregnancy treatment plan at 28 weeks?
- A. No dietary restriction (done 24-28 weeks' gestation)
Correct Answer: A
Rationale: The correct answer is A: No dietary restriction (done 24-28 weeks' gestation). This is because the glucose challenge test (GCT) is typically performed between 24-28 weeks of gestation to screen for gestational diabetes. It is important not to have any dietary restrictions before the test to ensure accurate results. Restricting food intake before the test can lead to false results. Other choices are incorrect because they do not align with the standard practice of performing the GCT between 24-28 weeks and avoiding dietary restrictions before the test.
A client at 37 weeks' gestation reports swollen feet and hands. What assessment finding requires immediate intervention?
- A. Blood pressure of 150/95 mmHg.
- B. Weight gain of 1 pound in a week.
- C. Mild nausea after eating.
- D. Fetal movements are regular.
Correct Answer: A
Rationale: The correct answer is A: Blood pressure of 150/95 mmHg. This finding indicates gestational hypertension, which can progress to preeclampsia, a serious condition that requires immediate intervention to prevent complications for both the mother and baby. High blood pressure can lead to organ damage and placental insufficiency.
B: Weight gain of 1 pound in a week is within the normal range for late pregnancy and may not require immediate intervention.
C: Mild nausea after eating is a common pregnancy symptom and does not indicate an urgent issue.
D: Regular fetal movements are a positive sign of fetal well-being and do not require immediate intervention.
What question during a family assessment could the nurse ask to determine if the family has necessary resources?
- A. Do you enjoy spending time with your family?
- B. Do you have a group of friends, neighbors, or a church that helps you when you are ill?
- C. How often do you go to the store by yourself?
- D. Do your family members get along well?
Correct Answer: B
Rationale: The correct answer is B: "Do you have a group of friends, neighbors, or a church that helps you when you are ill?" This question assesses the family's support network and resources in times of need. It helps determine if the family has a social support system that can provide assistance during challenging situations. Options A, C, and D are incorrect as they do not directly address the availability of external resources for the family's well-being. Option A focuses on emotional aspects, C on independence, and D on family dynamics, which are not directly related to assessing resources.
A 45-year-old woman presents to the clinic for advice about contraception. What is the most appropriate contraception method for a woman who is nearing menopause?
- A. Oral contraceptives with estrogen
- B. Contraceptive injections
- C. IUD with progestin
- D. Barrier methods like condoms
Correct Answer: C
Rationale: The most appropriate contraception method for a woman nearing menopause is an IUD with progestin (Choice C). Progestin-containing IUDs are effective, long-lasting, and suitable for women of various ages. As women approach menopause, the hormonal changes make progestin-containing IUD a favorable option as it offers reliable contraception without the need for daily administration. Additionally, progestin can also help alleviate symptoms like heavy periods that women may experience during perimenopause.
Choices A and B are not ideal as oral contraceptives with estrogen can increase the risk of blood clots in older women, and contraceptive injections may not be as convenient for someone nearing menopause. Barrier methods like condoms (Choice D) are less effective and may not provide the level of protection needed during this stage of life.
A client at 37 weeks' gestation reports severe itching without a rash. What condition should the nurse suspect?
- A. Preeclampsia.
- B. Cholestasis of pregnancy.
- C. Gestational diabetes.
- D. Fungal infection.
Correct Answer: B
Rationale: The correct answer is B: Cholestasis of pregnancy. Severe itching without a rash in a pregnant client at 37 weeks' gestation is concerning for cholestasis of pregnancy, a condition characterized by impaired bile flow. This can lead to elevated bile acids, causing itching. Preeclampsia (choice A) presents with hypertension and proteinuria. Gestational diabetes (choice C) manifests with high blood sugar levels. Fungal infection (choice D) typically presents with visible skin changes like a rash, which is absent in this case. In summary, cholestasis of pregnancy is the most likely explanation for severe itching in this scenario.