Nokea
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.
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After a dilatation and curettage(D&C) to evacuate a molar pregnancy, assessing the client for signs and symptoms of which of the following would be most important?
- A. Urinary tract infection.
- B. Hemorrhage.
- C. Abdominal distention.
- D. Chorioamnionitis.
Correct Answer: B
Rationale: Hemorrhage is a potential complication after D&C.
A 28-year-old multigravid client at 28 weeks' gestation diagnosed with acute pyelonephritis is receiving intravenous fluids and antibiotics. After teaching the client about the rationale for the aggressive therapy, the nurse determines that the client needs further instruction when she says that acute pyelonephritis can lead to which of the following?
- A. Preterm labor.
- B. Maternal sepsis.
- C. Intrauterine growth retardation.
- D. Congenital fetal anomalies.
Correct Answer: D
Rationale: Acute pyelonephritis can cause preterm labor, maternal sepsis, and intrauterine growth retardation due to infection and inflammation. Congenital fetal anomalies are not a direct consequence, indicating a need for further teaching.
Which of the following would alert the nurse to suspect that a neonate delivered at 34 weeks' gestation who is currently in an isolette with humidified oxygen and receiving intravenous fluids has developed overhydration?
- A. Hypernatremia.
- B. Polycythemia.
- C. Hypoproteinemia.
- D. Increased urine specific gravity.
Correct Answer: C
Rationale: Hypoproteinemia can result from overhydration, as excess fluid dilutes plasma proteins.
A client asks about the side effects of oral contraceptives. Which of the following would the nurse include in the response?
- A. Weight loss is a common side effect.
- B. Nausea and breast tenderness may occur initially.
- C. Hair loss is frequently reported.
- D. Oral contraceptives decrease the risk of breast cancer.
Correct Answer: B
Rationale: Nausea and breast tenderness are common initial side effects of oral contraceptives, which often subside. Weight gain, not loss, may occur, hair loss is not typical, and oral contraceptives do not significantly reduce breast cancer risk.
A female neonate delivered vaginally at term with a cleft lip and cleft palate is admitted to the regular nursery. Which of the following actions should the nurse do the first time that the parents visit the neonate in the nursery?
- A. Explain the surgical interventions that will be performed.
- B. Stress that this defect is not life-threatening.
- C. Emphasize the neonate's normal characteristics.
- D. Reassure the parents about the success rate of the surgery.
Correct Answer: C
Rationale: Emphasizing the neonate's normal characteristics helps promote bonding and reduces parental anxiety during the initial visit.