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A client at 34 weeks' gestation is diagnosed with polyhydramnios. What complication should the nurse monitor for?
- A. Preterm labor.
- B. Placental abruption.
- C. Fetal growth restriction.
- D. Cord prolapse.
Correct Answer: A
Rationale: Polyhydramnios increases the risk of preterm labor due to uterine overdistension.
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The nurse knows that the emancipated minor is considered to have the legal capacity of an adult and may make his or her own health care decisions. Which child would potentially be considered an emancipated minor?
- A. A minor with financial independence who is living with his parents
- B. A minor who is pregnant
- C. A child older than 13 years of age who asks for emancipation
- D. A minor who puts his or her medical decisions in writing
Correct Answer: B
Rationale: Emancipation may be considered in any of the following situations, depending on the state's laws: membership in a branch of the armed services, marriage, court-determined emancipation, financial independence and living apart from parents, college attendance, pregnancy, mother younger than 18 years of age, and a runaway.
The nurse is monitoring a client in labor. What finding indicates the transition phase?
- A. Cervix dilated to 4 cm.
- B. Cervix dilated to 8 cm.
- C. Irregular contractions.
- D. Client reports feeling the urge to push.
Correct Answer: B
Rationale: The transition phase is marked by cervical dilation of 8–10 cm, intense contractions, and significant discomfort.
The nurse is preparing a handout for female adolescents on the menstrual cycle. What phase of the cycle occurs if fertilization does not take place?
- A. Menstrual
- B. Proliferative
- C. Secretory
- D. Ischemic
Correct Answer: D
Rationale: The ischemic phase of the menstrual cycle occurs when the corpus luteum degenerates in the absence of fertilization. This leads to a decline in progesterone and estrogen levels, resulting in the shedding of the uterine lining during menstruation.
The nurse is reviewing a copy of the U.S. Surgeon General's Report, Healthy People 2020. Which nursing action best reflects the nurse fostering this health care agenda?
- A. The nurse signs up for classes to obtain an advanced degree in nursing.
- B. The nurse volunteers at a local health care clinic providing free vaccinations for low-income populations.
- C. The nurse performs an in-service on basic hospital equipment for student nurses.
- D. The nurse compiles nursing articles on evidence-based practices in nursing to present at a hospital training seminar.
Correct Answer: B
Rationale: Healthy People 2020 is a comprehensive health promotion and disease prevention agenda that is working toward improving the quantity and quality of life for all Americans.
The nurse is assessing a postpartum client who is breastfeeding. What finding requires further evaluation?
- A. Engorgement on day 3 postpartum.
- B. Mild nipple tenderness.
- C. Cracked and bleeding nipples.
- D. Colostrum present in the first 48 hours.
Correct Answer: C
Rationale: Cracked and bleeding nipples may indicate poor latch or incorrect breastfeeding technique, requiring intervention.