Nokea
Which of the following conditions should the nurse identify as being consistent with the adolescent's assessment findings? For each finding click to specify if the assessment findings are consistent with trichomoniasis, gonorrhea, or candidiasis. Each finding may support more than one disease process.
- A. Abdominal pain.
- B. Greenish discharge.
- C. Diabetes.
- D. Pain on urination.
- E. Absence of condom.
Correct Answer: B, D
Rationale: Greenish discharge and pain on urination are consistent with gonorrhea. Diabetes and absence of condom use are risk factors but not direct symptoms.
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A nurse is preparing to administer an IM injection to a newborn. Which of the following sites should the nurse select?
- A. Vastus lateralis
- B. Dorsogluteal
- C. Deltoid
- D. Rectus femoris
Correct Answer: A
Rationale: The correct answer is A: Vastus lateralis. For newborns, the vastus lateralis muscle is the preferred site for intramuscular injections due to its larger muscle mass and reduced risk of injury to nerves and blood vessels. It is located on the thigh, making it easily accessible and safe for administration. The deltoid muscle (choice C) is not recommended for newborns due to insufficient muscle mass. The dorsogluteal site (choice B) is not recommended for infants due to the proximity to the sciatic nerve. The rectus femoris (choice D) is not typically used for IM injections in newborns.
A nurse is assessing a client who gave birth vaginally 12 hr ago and palpates their uterus to the right above the umbilicus. Which of the following interventions should the nurse perform?
- A. Reassess the client in 2 hr.
- B. Administer simethicone.
- C. Assist the client to empty their bladder.
- D. Instruct the client to lie on their right side.
Correct Answer: C
Rationale: A displaced uterus to the right above the umbilicus may indicate a full bladder. Assisting the client to empty their bladder helps the uterus return to its proper position and prevents complications like postpartum hemorrhage.
Which of the following hormones is responsible for inducing ovulation?
- A. Estrogen
- B. Progesterone
- C. Follicle-stimulating hormone (FSH)
- D. Luteinizing hormone (LH)
Correct Answer: D
Rationale: The correct answer is D: Luteinizing hormone (LH). LH surge triggers ovulation by stimulating the release of the mature egg from the ovarian follicle. Estrogen and progesterone play roles in the menstrual cycle but do not directly induce ovulation. FSH is involved in follicular development but not ovulation.
A nurse is providing teaching to a client who is breastfeeding and experiencing engorgement. Which of the following recommendations should the nurse include?
- A. Apply warm compresses on the breasts before feedings
- B. Allow the infant to nurse on one breast per feeding.
- C. Take aspirin to reduce pain and swelling.
- D. Wear a tight-fitting underwire bra.
Correct Answer: A
Rationale: Warm compresses help to relieve engorgement by promoting milk flow and reducing discomfort before feedings.
A nurse is caring for a client who is receiving oxytocin via continuous IV infusion and is experiencing persistent late decelerations in the FHR. After discontinuing the infusion, which of the following actions should the nurse take?
- A. Instruct the client to bear down and push with contractions.
- B. Administer oxygen at 10 L/min via nonrebreather facemask.
- C. Place the client in a supine position.
- D. Initiate an amnioinfusion.
Correct Answer: B
Rationale: The correct answer is B: Administer oxygen at 10 L/min via nonrebreather facemask. Late decelerations in FHR during oxytocin infusion indicate uteroplacental insufficiency. Administering oxygen helps improve oxygenation to the fetus, potentially alleviating the late decelerations. This action addresses the underlying cause and supports fetal oxygenation. In contrast, option A may increase intrauterine pressure, worsening fetal distress. Option C (supine position) can further compromise placental perfusion. Option D (amnioinfusion) is used for variable decelerations, not late decelerations.