Nokea
The physician has ordered an injection of RhoGam for a client with blood type A negative. The nurse knows that RhoGam is given at:
- A. One finger breadth below the umbilicus
- B. The deltoid
- C. Two finger breadths above the trochanter
- D. Two finger breadths below the umbilicus
Correct Answer: B
Rationale: RhoGam is administered intramuscularly, typically in the deltoid muscle, for Rh-negative mothers to prevent sensitization. The other locations are incorrect for IM injections of RhoGam.
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The parents of a 2-year-old child are ready to begin toilet training activities with him. His parents feel he is ready to train because he is now 2 years old. What would the nurse identify as readiness in this child?
- A. Patience by the child when wearing soiled diapers
- B. Communicating the urge to defecate or urinate
- C. The child awakening wet from his naps
- D. The age at which the child's siblings were trained
Correct Answer: B
Rationale: A child must be able to use verbal or nonverbal skills to communicate needs, indicating readiness for toilet training.
The nurse is providing dietary instructions for a client with iron-deficiency anemia. Which food is a poor source of iron?
- A. Tomatoes
- B. Legumes
- C. Dried fruits
- D. Nuts
Correct Answer: A
Rationale: Tomatoes are a poor source of iron compared to legumes, dried fruits, and nuts, which are rich in iron. Tomatoes provide vitamin C, which aids iron absorption, but lack significant iron content.
MgSO4 is ordered IV following the established protocol for a client with severe PIH. The anticipated effects of this therapy are anticonvulsant and:
- A. Vasoconstrictive
- B. Vasodilative
- C. Hypertensive
- D. Antiemetic
Correct Answer: B
Rationale: An anticonvulsant effect is the goal of drug therapy for PIH. However, we would not want to increase the vasoconstriction that is already present. This would make the symptoms more severe. An anticonvulsant effect and vasodilation are the desired outcomes when administering this drug. An anticonvulsant effect is the goal of drug therapy for PIH; however, hypertensive drugs would increase the blood pressure even more. An anticonvulsant effect is the goal of drug therapy for PIH. MgSO4 is not classified as an antiemetic. Antiemetics are not indicated for PIH treatment.
An amniocentesis at 32 weeks gestation reveals that a multigravida with diabetes has an L/S ratio of 1:1 with the presence of phosphatidylglycerol. Based on the amniocentesis,the nurse knows that if delivered now:
- A. The newborn is at low risk for congenital anomalies.
- B. The newborn is at high risk for intrauterine growth retardation.
- C. The newborn is at high risk for respiratory distress syndrome.
- D. The newborn is at high risk for birth trauma.
Correct Answer: C
Rationale: An L/S ratio of 1:1 at 32 weeks indicates immature fetal lungs increasing the risk of respiratory distress syndrome (RDS) if delivered now. Phosphatidylglycerol presence is positive but does not fully mitigate RDS risk. The other risks are not directly related to the L/S ratio.
A client is being evaluated for carpal tunnel syndrome. The nurse is observed tapping over the median nerve in the wrist and asking the client if there is pain or tingling. Which assessment is the nurse performing?
- A. Phalen's maneuver
- B. Tinel's sign
- C. Kernig's sign
- D. Brudzinski's sign
Correct Answer: B
Rationale: Tinel’s sign involves tapping the median nerve to elicit pain/tingling in carpal tunnel syndrome. Phalen’s maneuver (A) involves wrist flexion, Kernig’s (C) and Brudzinski’s (D) are for meningitis.