Nokea
What serum laboratory reports would the nurse expect in a bulimic client?
- A. Potassium 3.0 mEq/L.
- B. Bicarbonate 30 mmol/L.
- C. Platelet count 450,000 cells/mm3.
- D. Hemoglobin A1C 9%.
Correct Answer: A
Rationale: Low potassium levels result from vomiting and purging.
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A nurse on a labor unit is admitting a client who reports painful contractions. The nurse determines that the contractions have a duration of 1 min and a frequency of 3 min. The nurse obtains the following vital signs: fetal heart rate 130/min, maternal heart rate 128/min and maternal blood pressure 92/54 mm Hg. Which of the following is the priority action for the nurse to take?
- A. Notify the provider of the findings.
- B. Position the client with one hip elevated.
- C. Ask the client if she needs pain medication.
- D. Have the client void.
Correct Answer: A
Rationale: The priority action for the nurse in this situation is to notify the provider of the vital signs and the client's condition. The maternal blood pressure of 92/54 mm Hg is low, which can indicate hypotension. Hypotension during labor can lead to decreased perfusion to both the mother and baby, potentially causing harm. Therefore, the provider needs to be notified promptly so that appropriate interventions can be initiated to address the maternal hypotension and ensure the well-being of both the mother and the baby. Positioning the client with one hip elevated, asking about pain medication, and having the client void can be important interventions, but they are not the priority in this situation where maternal hypotension is a concern.
The pediatric nurse would be participating in the role of advocate when completing which action?
- A. Instructing parents on the side effects of vaccinations they are requesting for their child
- B. Contributing input on a task force with the aim to reduce the rate of mortality of infants and children
- C. Teaching parents to keep their prescribed medication safely out of reach of children
- D. Explaining to parents the reason for each medication their child was recently prescribed
Correct Answer: B
Rationale: The role of advocacy is being fulfilled when the nurse works to safeguard and advance the interest of children and infants through many means, including contributing to the learning and application of a task force aimed at reducing infant and children mortality.
Screening at 24 weeks gestation reveals that a pregnant woman has gestational diabetes mellitus (GDM). In planning the woman9s care. The nurse and the woman mutually agree that an expected outcome is to prevent injury to the fetus due to the GDM. The nurse identifies that the fetus is at risk for which of the following? Congenital anomalies of the central nervous system Macrosomia Preterm birth Low birth weight Screening at 24 weeks of gestation reveals that a pregnant woman has gestational diabetes mellitus (GDM). In planning her care, the nurse and the woman mutually agree that an expected outcome is to prevent injury to the fetus as a result of GDM. The nurse identifies that the fetus is at greatest risk for:
- A. macrosomia.
- B. congenital anomalies of the central nervous system.
- C. preterm birth.
- D. low birth weight. A
Correct Answer: A
Rationale: Gestational diabetes mellitus (GDM) is a condition where high blood sugar levels develop during pregnancy in women who didn't have diabetes before pregnancy. One of the primary risks associated with GDM is fetal overgrowth, also known as macrosomia. This means the baby is larger than normal. Macrosomia can lead to complications during delivery, such as shoulder dystocia (when the baby's shoulders get stuck during delivery) and an increased risk of birth injuries for both the baby and the mother. It can also increase the likelihood of a cesarean section delivery. Therefore, preventing macrosomia is an important goal in managing GDM to ensure the safety and well-being of both the mother and the baby.
Most newborns receive a prophylactic injection of vitamin K soon after birth. Which site is appropriate for the newborn?
- A. Gluteal muscles
- B. Rectus femoris muscle
- C. Deltoid muscle
- D. Vastus lateralis muscle
Correct Answer: D
Rationale: Vastus lateralis muscle is the recommended site due to its size and safety.
Which finding would lead the nurse to suspect toxic shock syndrome related to tampon use?
- A. Diffuse rash with fever.
- B. Angina.
- C. Hypertension.
- D. Thrombocytopenia with pallor.
Correct Answer: A
Rationale: Toxic shock syndrome often presents with a diffuse rash and fever.