Nokea
Which complaint made by a patient at 35 weeks of gestation requires additional assessment?
- A. Abdominal pain
- B. Ankle edema in the afternoon
- C. Backache with prolonged standing
- D. Shortness of breath when climbing stairs
Correct Answer: A
Rationale: The correct answer is A: Abdominal pain. This complaint at 35 weeks of gestation requires additional assessment as it could indicate a serious issue such as preterm labor, placental abruption, or other complications. Abdominal pain in late pregnancy should never be ignored. Ankle edema in the afternoon, backache with prolonged standing, and shortness of breath when climbing stairs are common discomforts in pregnancy and may not necessarily indicate a serious problem at this stage.
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The nurse is caring for a client who is scheduled to have an amniocentesis. Which intervention is most important for the nurse to perform after the procedure?
- A. Evaluate need for Rh0D immunoglobulin
- B. Clean site
- C. Administer pain medication
- D. Perform vital signs
Correct Answer: A
Rationale: The correct answer is A: Evaluate need for Rh0D immunoglobulin. After an amniocentesis, it is crucial to assess if the client is Rh-negative and the fetus is Rh-positive. If this is the case, Rh0D immunoglobulin should be administered to prevent Rh incompatibility issues in future pregnancies. This intervention is critical to prevent hemolytic disease in the newborn.
Cleaning the site (B) is important for infection prevention but not the most critical post-procedure intervention. Administering pain medication (C) can be done based on client's discomfort level but not the top priority. Performing vital signs (D) is important but assessing Rh status and administering Rh0D immunoglobulin take precedence.
In which type of health care facility does the nurse want to work if applying for a position with a home care organization that specializes in spinal cord injury?
- A. Secondary acute
- B. Continuing
- C. Restorative
- D. Tertiary
Correct Answer: C
Rationale: Patients recovering from an acute or chronic illness or disability often require additional services (restorative care) to return to their previous level of function or reach a new level of function limited by their illness or disability.
The nurse reports a nonreactive NST to the physician. The physician orders vibroacoustic stimulation. Which does the nurse understand the appropriate application for the vibroacoustic stimulation to be? Select all that apply.
- A. Clap loudly by the fetal head
- B. Apply a sterile drape to abdomen prior to stimulation
- C. Apply the artificial larynx stimulus by the fetal head
- D. Limit the use of the artificial larynx stimulus to three times
Correct Answer: C
Rationale: The correct answer is C: Apply the artificial larynx stimulus by the fetal head. Vibroacoustic stimulation involves using sound waves to stimulate the fetus and provoke a response, particularly in cases of nonreactive nonstress test (NST). By applying the artificial larynx stimulus near the fetal head, the nurse ensures direct and effective stimulation of the fetus. This method has been found to be safe and effective in improving fetal heart rate reactivity.
Incorrect Choices:
A: Clap loudly by the fetal head - This is not an appropriate method for vibroacoustic stimulation as it may not provide the controlled and targeted stimulation needed.
B: Apply a sterile drape to abdomen prior to stimulation - This is not necessary for vibroacoustic stimulation and does not contribute to its effectiveness.
D: Limit the use of the artificial larynx stimulus to three times - There is no specific limit to the number of times vibroacoustic stimulation can be applied, as it depends on the
A woman, who is in pain from a diagnosis of mastitis, has abruptly weaned her baby to a bottle. Her actions place the woman at high risk for which of the following?
- A. Mammary rupture.
- B. Postpartum psychosis.
- C. Supernumerary nipples.
- D. Breast abscess.
Correct Answer: D
Rationale: Abrupt weaning can lead to milk stasis, increasing the risk of a breast abscess due to bacterial infection.
During a postpartum examination, the nurse notes that a client’s left calf is warm and swollen. Which of the following actions by the nurse is appropriate at this time?
- A. Notify the client’s physician.
- B. Teach the client to massage her leg.
- C. Apply ice packs to the client’s leg.
- D. Encourage the client to ambulate.
Correct Answer: A
Rationale: A warm, swollen calf may indicate deep vein thrombosis (DVT), a serious condition requiring immediate medical attention.