Nokea
Which of the following findings require follow-up?
- A. 30-year-old client at 33 weeks gestation, Gravida 4 Para 3
- B. CBC and urinalysis collected and sent to lab.
- C. Maternal blood type: Rh+
- D. Last pregnancy resulted in a preterm spontaneous vaginal birth at 30 weeks gestation.
- E. Client reports lower back pain and pinkish vaginal discharge.
- F. Uterine contractions every 8 minutes, palpate strong, duration 30 seconds,
- G. FHR baseline 145, minimal variability.
Correct Answer: E,F,G
Rationale: The correct answers are E, F, and G because they indicate potential complications during pregnancy.
E: Lower back pain and pinkish vaginal discharge can be signs of preterm labor or placental issues, requiring immediate follow-up.
F: Uterine contractions every 8 minutes, strong palpation, and duration 30 seconds suggest active labor, needing monitoring for progression.
G: Fetal heart rate (FHR) baseline of 145 with minimal variability may indicate fetal distress, necessitating further assessment.
Other choices are routine findings or do not pose immediate risks, such as A (normal obstetric history), B (routine lab tests), C (Rh+ blood type is common), and D (history of preterm birth but no current concerns).
You may also like to solve these questions
Which of the following actions should the nurse take first?
- A. Determine the client's Glasgow Coma Scale score
- B. Insert an indwelling urinary catheter for the client.
- C. Administer mannitol IV bolus to the client
- D. Prepare the client for an MRI of the brain.
Correct Answer: A
Rationale: The correct answer is A: Determine the client's Glasgow Coma Scale (GCS) score. This is the priority action as it helps assess the client's level of consciousness and neurological status quickly. It guides further interventions and treatment decisions. Inserting an indwelling urinary catheter (B) or administering mannitol IV bolus (C) may be needed but assessing neurological status comes first. Preparing for an MRI (D) is important but not the initial step.
Which of the following questions is the priority for the nurse to ask the client?
- A. How do you manage your behavior?
- B. Do you have a criminal record?
- C. How do you get along with your peers at school?
- D. Do you have thoughts of harming yourself?
Correct Answer: D
Rationale: The correct answer is D. The nurse's priority is to assess for any immediate danger or harm to the client. Asking about thoughts of harming oneself is crucial in determining the client's safety. This question helps identify the client's risk of suicide and allows for timely intervention if needed. Choices A, B, and C focus on different aspects of the client's behavior and relationships, which are important but not as urgent as assessing for suicidal ideation. It is essential to address safety concerns first before exploring other areas.
Select the 3 statements the nurse should include in the teaching.
- A. Notify your provider if you experience vomiting or diarrhea.
- B. Limit alcohol intake to no more than one drink per day
- C. You should eat foods that are low in fat.
- D. You can drink beverages that contain caffeine.
- E. You should eat foods highs in protein.
Correct Answer: A,B,C
Rationale: The correct answers are A, B, and C. A is important as vomiting and diarrhea can lead to dehydration. B is crucial for liver health and overall well-being. C is essential for heart health and maintaining a healthy weight. The other choices are incorrect. D can worsen symptoms and interfere with medication. E may not be suitable for certain health conditions and can lead to weight gain. No information is provided for options F and G.
A nurse is caring for a client who has acute glomerulonephritis. Which of the following findings should the nurse expect?
- A. Polyuria
- B. Hypotension
- C. Weight loss
- D. Hematuria
Correct Answer: D
Rationale: The correct answer is D: Hematuria. In acute glomerulonephritis, there is inflammation of the glomeruli in the kidneys leading to blood in the urine. This is known as hematuria. Polyuria (choice A) is not typically seen in this condition as the kidneys are not able to effectively filter urine. Hypotension (choice B) is unlikely as fluid retention and hypertension are more common due to decreased kidney function. Weight loss (choice C) is not a common finding as the condition often leads to fluid retention. Therefore, hematuria is the most expected finding in acute glomerulonephritis.
Which of the following anterior chest wall locations should the nurse auscultate?(You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.)
Correct Answer:
Rationale: Correct Answer: D (Second intercostal space, right sternal border)
Rationale: The nurse should auscultate at the second intercostal space, right sternal border to listen to the aortic valve. This location corresponds to the area where the aortic valve can be best heard. The aortic valve is located in the second intercostal space, right sternal border, so auscultating at this spot allows for accurate assessment of the heart sounds in this area. It is essential to auscultate at this specific location to detect any abnormalities or abnormalities in the aortic valve.
Summary of other choices:
- A, B, C, E, F, G: These locations do not correspond to the specific area where the aortic valve is best heard. Auscultating at these locations may not provide clear or accurate heart sounds related to the aortic valve.