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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: The correct answer is B, D . Abdominal pain (A) is not specific to any of the given conditions. Diabetes (C) is not directly related to the assessment findings provided. Absence of condom (E) is not an assessment finding, but a behavior. Trichomoniasis is characterized by greenish discharge, and pain on urination can be a symptom of both gonorrhea and trichomoniasis.
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A nurse is caring for a client who is 1 hr postpartum and has uterine atony. The client is exhibiting a large amount of vaginal bleeding. Which of the following actions should the nurse take?
- A. Administer betamethasone IM.
- B. Avoid performing sterile vaginal examinations.
- C. Anticipate a prescription for misoprostol.
- D. Obtain a specimen for a Kleihauer-Betke test.
Correct Answer: C
Rationale: The correct answer is C: Anticipate a prescription for misoprostol. Misoprostol is a medication commonly used to manage postpartum hemorrhage due to uterine atony. It helps to promote uterine contractions and control bleeding. Administering betamethasone (A) is not indicated in this situation as it is a steroid used for fetal lung maturation. Avoiding sterile vaginal examinations (B) may delay the identification of the cause of bleeding. Obtaining a specimen for a Kleihauer-Betke test (D) is used to determine the amount of fetal-maternal hemorrhage and is not the immediate priority in managing uterine atony.
Which of the following nursing actions should the nurse plan to take? For each potential nursing action, click to specify it the intervention is indicated or contraindicated for the client.
- A. Insert a large bore intravenous catheter.
- B. Assess cervical dilation.
- C. Weigh perineal pads.
- D. Administer methotrexate.
Correct Answer: A, C
Rationale: [, (0, 0, 0), (1, 0, 0), (0, 0, 1)]
Correct Answer: A, C
Rationale:
A: Inserting a large bore intravenous catheter is indicated for quick and efficient fluid administration in emergencies or critical conditions.
C: Weighing perineal pads helps monitor postpartum hemorrhage accurately by assessing the amount of blood loss.
Assessing cervical dilation (B) is not indicated unless specified for a specific medical condition. Administering methotrexate (D) is contraindicated in pregnancy and certain medical conditions.
A nurse is caring for an infant who has signs of neonatal abstinence syndrome. Which of the following actions should the nurse take?
- A. Monitor blood glucose level every hr.
- B. Place the infant on his back with legs extended.
- C. Initiate seizure precautions.
- D. Provide a stimulating environment.
Correct Answer: C
Rationale: The correct answer is C: Initiate seizure precautions. Neonatal abstinence syndrome can result in neurological symptoms, including seizures. Initiating seizure precautions involves ensuring a safe environment, padding the crib, and closely monitoring the infant for any signs of seizure activity. Monitoring blood glucose every hour (A) is not typically indicated for neonatal abstinence syndrome. Placing the infant on his back with legs extended (B) is a standard safe sleep practice but is not specific to managing neonatal abstinence syndrome. Providing a stimulating environment (D) can exacerbate symptoms of withdrawal and should be avoided.
A nurse manager on the labor and delivery unit is teaching a group of newly licensed nurses about maternal cytomegalovirus. Which of the following information should the nurse manager include in the teaching?
- A. Mothers will receive prophylactic treatment with acyclovir prior to delivery.
- B. Transmission can occur via the saliva and urine of the newborn.
- C. Lesions are visible on the mother’s genitalia.
- D. This infection requires that airborne precautions be initiated for the newborn.
Correct Answer: B
Rationale: The correct answer is B. Maternal cytomegalovirus can be transmitted to the newborn through saliva and urine. This is important for healthcare providers to understand as it influences infection control practices in the care of both the mother and the newborn. The other choices are incorrect because: A) Acyclovir is used to treat herpes simplex virus, not cytomegalovirus. C) Lesions are not typically visible on the mother's genitalia with cytomegalovirus. D) Airborne precautions are not required for cytomegalovirus as it is primarily transmitted through bodily fluids.
A nurse is teaching about clomiphene citrate to a client who is experiencing infertility. Which of the following adverse effects should the nurse include?
- A. Breast tenderness
- B. Tinnitus
- C. Urinary frequency
- D. Chills
Correct Answer: A
Rationale: The correct answer is A: Breast tenderness. Clomiphene citrate is a medication commonly used to treat infertility by inducing ovulation. One of its common side effects is breast tenderness due to its estrogenic effects. This occurs as a result of increased estrogen levels associated with the drug. Tinnitus (B), urinary frequency (C), and chills (D) are not typically associated with clomiphene citrate use. Tinnitus is more commonly linked to medications affecting the ear, urinary frequency is not a common side effect of clomiphene citrate, and chills are not a typical adverse effect of this medication.