Nokea
Which finding should the nurse expect?
- A. Spotting
- B. Painless, bright red vaginal bleeding
- C. Soft, relaxed, and non-tender uterus
- D. Fundal height greater than expected for gestational age
- E. Fetal heart rate within normal limits unless significant blood loss occurs
Correct Answer: B
Rationale: The correct answer is B: Painless, bright red vaginal bleeding. This finding is indicative of placenta previa, a condition where the placenta partially or completely covers the cervix. The bright red color indicates fresh bleeding. Spotting (choice A) is more commonly associated with implantation bleeding in early pregnancy. A soft, relaxed, and non-tender uterus (choice C) is not specific to any particular condition. A fundal height greater than expected for gestational age (choice D) could indicate fetal macrosomia or polyhydramnios, but it is not related to the scenario described. While fetal heart rate within normal limits (choice E) is important, it is not the most relevant finding in this case.
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Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing.
- A. Ensure that client has intake of at least 200mL/hr
- B. Initiate contact precautions
- C. Prepare client for light therapy
- D. Sickle cell crisis
- E. Psoriasis
- F. Osteomyelitis
Correct Answer: B,C
Rationale: Increased fluid intake and contact precautions are essential for managing systemic lupus erythematosus.
The nurse should recognize which of the following findings as a potential contraindication for using lavender?
- A. The client has a history of asthma
- B. The client takes furosemide twice daily
- C. The client has a history of alcohol use disorder
- D. The client takes vitamin C daily
Correct Answer: A
Rationale: The correct answer is A: The client has a history of asthma. Lavender can trigger asthma symptoms due to its volatile organic compounds. People with asthma may experience worsened symptoms or even asthma attacks when exposed to lavender. Asthma is a contraindication as it can lead to serious health complications.
Explanation for other choices:
B: The client takes furosemide twice daily - Furosemide is a diuretic and does not interact significantly with lavender.
C: The client has a history of alcohol use disorder - Alcohol use disorder does not directly contraindicate the use of lavender.
D: The client takes vitamin C daily - Vitamin C does not interact significantly with lavender.
Fill in the blanks with one condition and one client finding.The client is most likely experiencing---------- as evidenced by the client's--------
- A. Mania
- B. Delirium
- C. Catatonia
- D. Magical thinking
- E. Euphoric mood
- F. Hypervigilance
- G. Panic disorder
Correct Answer: A,E
Rationale: The correct answer is A, E. Mania is characterized by elevated mood, increased energy levels, and impulsivity. The client is most likely experiencing mania as evidenced by euphoric mood. Euphoric mood is a key symptom of mania, reflecting a heightened sense of well-being and happiness. Therefore, the combination of mania and euphoric mood is indicative of a manic episode. Choices B, C, D, F, and G are incorrect as they do not align with the symptoms and presentation of mania. Delirium is characterized by confusion and disorientation, not euphoric mood. Catatonia involves motor disturbances, not euphoric mood. Magical thinking refers to unrealistic beliefs, not necessarily elevated mood. Hypervigilance is associated with anxiety disorders, not mania. Panic disorder is characterized by recurrent panic attacks, not euphoric mood.
Which action should the nurse include in the plan?
- A. Minimize noise in the newborn's environment.
- B. Swaddle the newborn loosely to allow free movement.
- C. Position the newborn supine with legs extended.
- D. Encourage frequent handling and stimulation.
Correct Answer: A
Rationale: The correct answer is A because minimizing noise in the newborn's environment is crucial for promoting rest and reducing stress. Newborns are highly sensitive to loud noises, which can disrupt their sleep and affect their overall well-being. By creating a quiet environment, the nurse helps the newborn to feel secure and comfortable, promoting better sleep and overall development.
Choice B is incorrect because swaddling the newborn loosely may pose a suffocation risk and restrict movement, which is not recommended. Choice C is incorrect as positioning the newborn supine with legs extended may increase the risk of sudden infant death syndrome (SIDS). Choice D is also incorrect as encouraging frequent handling and stimulation can overwhelm the newborn's developing nervous system and lead to increased stress.
Which of the following actions should the nurse take?
- A. Provide the client with cold foods rather than hot foods
- B. Encourage the client to drink fluids with meals
- C. Offer the client large meals three times a day
- D. Advise the client to avoid high-protein foods
Correct Answer: A
Rationale: The correct answer is A because providing the client with cold foods rather than hot foods can help reduce nausea and vomiting, which are common symptoms of pregnancy. Cold foods are generally better tolerated by pregnant women experiencing morning sickness. Encouraging the client to drink fluids with meals (choice B) is important, but it is not the most immediate action to alleviate nausea. Offering the client large meals three times a day (choice C) may worsen nausea, as smaller, more frequent meals are typically recommended. Advising the client to avoid high-protein foods (choice D) is not necessary unless there are specific contraindications, as protein is important for fetal development.