Nokea
When assessing a 16-year-old primigravid client at 37 weeks' gestation diagnosed with severe preeclampsia, which of the following indicates the client needs continued management for the preeclampsia?
- A. Blood pressure of 138/94 mm Hg.
- B. Severe blurring of vision.
- C. Less than 2 g of protein in a 24-hour sample.
- D. Weight gain of 0.5 lb in 1 week.
Correct Answer: B
Rationale: Severe blurring of vision indicates worsening preeclampsia.
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When assessing a 34-year-old multigravid client at 34 weeks' gestation experiencing moderate vaginal bleeding, which of the following would most likely alert the nurse that placenta previa is present?
- A. Painless vaginal bleeding.
- B. Uterine tetany.
- C. Intermittent pain with spotting.
- D. Dull lower back pain.
Correct Answer: A
Rationale: Painless vaginal bleeding is characteristic of placenta previa.
A client asks about the risks of the contraceptive injection. Which of the following would the nurse include?
- A. Increased risk of blood clots.
- B. Decreased bone density with long-term use.
- C. Permanent weight loss.
- D. Guaranteed regular periods.
Correct Answer: B
Rationale: The contraceptive injection may decrease bone density with long-term use, which is a significant risk. It does not significantly increase blood clot risk, cause permanent weight loss, or guarantee regular periods.
The nurse is to assess a newborn for incurving of the trunk. Which illustration indicates the position in which the nurse should place the newborn?
Correct Answer: B
Rationale: To assess for incurving of the trunk, the newborn should be placed in a side-lying position to observe spinal curvature.
While the nurse is caring for a primiparous client on the first postpartum day, the client asks, "How is that woman doing who lost her baby from prematurity?" Which of the following responses by the nurse would be most appropriate?
- A. Ignore the client's question and continue with morning care.
- B. Tell the client "I'm not sure how the other woman is doing today."
- C. Tell the client "I need to ask the woman's permission before discussing her well-being."
- D. Explain to the client that "Nurses are not allowed to discuss other clients on the unit."
Correct Answer: D
Rationale: Nurses must maintain patient confidentiality, making it inappropriate to discuss another client's status.
A nurse is explaining basic principles of asepsis and infection control to a client who has a respiratory tract infection following delivery. The nurse determines the client understands principles of infection control to follow when the client says:
- A. I must use barrier isolation.
- B. I must wear a gown and gloves.
- C. I must use individual client care equipment.
- D. I must practice frequent hand washing.
Correct Answer: D
Rationale: Frequent hand washing is the most effective infection control measure for a respiratory tract infection.