Nokea
Which of the following findings should the nurse report to the provider? (Select all that apply.)
- A. Coombs test result
- B. Mucous membrane assessment
- C. Intake and output
- D. Respiratory rate
- E. Head assessment finding
- F. Heart rate
- G. Sclera color
Correct Answer: A,B,C,G
Rationale:
You may also like to solve these questions
The nurse is preparing the infant for phototherapy.For each nursing action, click to specify if the action is indicated or contraindicated for the newborn.
- A. Supplement feeding with sterile water.
- B. Dress in only a diaper.
- C. Cover newborn's eyes with a shield
- D. Apply lotion to skin every 4 Mr.
- E. Breastfeed every 2 to 3 hr.
Correct Answer:
Rationale: Increase IV fluids for better circulation
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 assessing the fontanels of an 8-month-old infant. Which of the following findings should the nurse recognize as an expected finding?
- A. The posterior fontanel is open.
- B. The anterior fontanel is open
- C. Both fontanels are the same size.
- D. Both fontanels show molding.
Correct Answer: B
Rationale: The anterior fontanel typically remains open until around 18 months of age, while the posterior fontanel usually closes by 2-3 months. Molding is not an expected finding at this age.
Complete the following sentence by using the list of options. Based on the client findings, the nurse should first admister-----------------and then prepare to administer-----------------------
- A. calcium gluconate
- B. hydralazine
- C. nifedipine
Correct Answer: B,A
Rationale: Rationale:
First administer hydralazine ✅
The client is experiencing severe hypertension (BP 170/112 mm Hg at 1400), which indicates preeclampsia with severe features.
Hydralazine is a fast-acting antihypertensive that helps lower blood pressure and reduce the risk of stroke, placental abruption, or fetal compromise.
Then prepare to administer calcium gluconate ✅
If the client is receiving magnesium sulfate for seizure prevention (common in severe preeclampsia), calcium gluconate is the antidote in case of magnesium toxicity (which can cause respiratory depression or cardiac arrest).
The nurse should have calcium gluconate readily available in case of toxicity signs like loss of deep tendon reflexes, respiratory depression, or cardiac arrhythmias.
Notify the provider 🚨
The severely elevated BP (170/112 mm Hg) and potential risk for eclampsia (seizures) require immediate provider notification for further management.
What is the primary hormone responsible for maintaining the endometrium during pregnancy?
- A. Progesterone
- B. Estrogen
- C. Follicle-stimulating hormone (FSH)
- D. Luteinizing hormone (LH)
Correct Answer: A
Rationale: The correct answer is A: Progesterone. Progesterone is the primary hormone responsible for maintaining the endometrium during pregnancy. It helps to thicken the endometrial lining, ensuring a suitable environment for implantation and supporting the developing embryo. Progesterone also inhibits uterine contractions, preventing premature labor. Estrogen, FSH, and LH do not play a primary role in maintaining the endometrium during pregnancy. Estrogen is involved in the initial thickening of the endometrium, while FSH and LH are primarily responsible for ovulation and follicle development.