Nokea
A nurse is caring for a client who is pregnant in an antepartum clinic.
Vital Signs
0900:
Temperature 36.6°C (97.9°F)
Heart rate 88/min
Respiratory rate 18/min
Blood pressure 130/70 mm Hg
Oxygen saturation 97% on room air
1000:
Heart rate 76/min
Respiratory rate 20/min
Blood pressure 138/68 mm Hg
Oxygen saturation 98% on room air
Which of the following findings should the nurse report to the provider?Select the 3 findings that should be reported.
- A. Uterine contractions
- B. Fetal heart rate
- C. Gestational age
- D. Vaginal examination
- E. Maternal blood pressure
Correct Answer: A,B,D
Rationale: The nurse should report uterine contractions (A) to monitor for preterm labor, fetal heart rate (B) to assess fetal well-being, and vaginal examination (D) to evaluate cervical changes. Gestational age (C) is typically known and doesn't require immediate reporting. Maternal blood pressure (E) is important but not a priority in this context.
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A nurse in a clinic is caring for a 16-year-old adolescent.
Exhibit 1
History and Physical
Adolescent is sexually active with two current partners.
IUD in place
Reports not using condoms during sexual activity.
History of type 1 diabetes mellitus”
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: To determine the correct answer, we need to identify which assessment findings are consistent with trichomoniasis, gonorrhea, or candidiasis.
B: Greenish discharge is consistent with both trichomoniasis and gonorrhea due to their characteristic discharge color.
D: Pain on urination is a common symptom of gonorrhea, making it consistent with this condition.
Therefore, the correct answer is , as Greenish discharge and Pain on urination are consistent with gonorrhea. Abdominal pain and Diabetes are not specific to any of the mentioned conditions.
A nurse is assessing a client who is postpartum and has idiopathic thrombocytopenia purpura (ITP). Which of the following findings should the nurse expect?
- A. Decreased platelet count.
- B. Increased erythrocyte sedimentation rate (ESR).
- C. Decreased megakaryocytes.
- D. Increased WBC.
Correct Answer: A
Rationale: The correct answer is A: Decreased platelet count. In idiopathic thrombocytopenia purpura (ITP), there is a decrease in platelet count due to immune-mediated destruction of platelets. This can lead to an increased risk of bleeding.
Explanation for other choices:
B: Increased erythrocyte sedimentation rate (ESR) is not typically associated with ITP.
C: Decreased megakaryocytes may be seen in some cases of ITP but is not a consistent finding.
D: Increased WBC is not a characteristic finding in ITP.
Therefore, the most relevant finding in a client with ITP would be a decreased platelet count due to the underlying pathophysiology of the condition.
The nurse is reviewing laboratory results in the adolescent's medical
record.
Exhibit 1
History and Physical
Adolescent is sexually active with two current partners.
IUD in place
Reports not using condoms during sexual activity.
History of type 1 diabetes mellitus
The nurse suspects the adolescent is experiencing pelvic inflammatory disease and is planning care. Which of the following prescriptions should the nurse expect the provider to prescribe? Drag words from the choices below to fill in each blank in the following sentence. The nurse should anticipate a provider's prescription for ------------------------------ and --------------------------
- A. fuconazole
- B. doxycycline
- C. Ceftriaxone
- D. acyclovir
- E. imiquimod
Correct Answer: B,C
Rationale: The correct answer is B (doxycycline) and C (Ceftriaxone). Pelvic inflammatory disease (PID) is commonly treated with antibiotics to target the infection. Doxycycline and Ceftriaxone are effective antibiotics for treating PID caused by common pathogens like Chlamydia and Gonorrhea. Doxycycline is a broad-spectrum antibiotic that works by inhibiting bacterial protein synthesis, while Ceftriaxone is a third-generation cephalosporin that disrupts bacterial cell wall synthesis. These medications are commonly prescribed in combination to cover a broader spectrum of potential pathogens causing PID. Choice A (fuconazole) is an antifungal medication and is not appropriate for treating PID. Choice D (acyclovir) is an antiviral medication used to treat herpes infections, which are not associated with PID. Choice E (imiquimod) is an immune response modifier used for treating certain skin conditions and
A nurse is providing teaching to the parents of a newborn about newborn genetic screening. Which of the following statements should the nurse Include in the teaching?
- A. This test will be repeated when your baby is 2 months old.
- B. A nurse will draw blood from your baby's inner elbow.
- C. This test should be performed after your baby is 24 hours old.
- D. Your baby will be given 2 ounces of water to drink prior to the test.
Correct Answer: C
Rationale: Rationale: The correct answer is C because newborn genetic screening should be performed after the baby is 24 hours old to ensure accurate results. Testing too early may lead to false negatives. Choice A is incorrect because the test is typically done once soon after birth. Choice B is incorrect as blood is usually drawn from the baby's heel, not inner elbow. Choice D is incorrect as newborns should not be given water before the test due to risk of aspiration.
A school nurse is providing teaching to an adolescent about levonorgestrel contraception. Which of the following information should the nurse include in the teaching?
- A. You should take the medication within 72 hours following unprotected sexual intercourse.
- B. You should avoid taking this medication if you are on an oral contraceptive.
- C. If you don't start your period within 5 days of taking this medication, you will need a pregnancy test.
- D. One dose of this medication will prevent you from becoming pregnant for 14 days after taking it.
Correct Answer: A
Rationale: The correct answer is A: You should take the medication within 72 hours following unprotected sexual intercourse. Levonorgestrel is a type of emergency contraception that is most effective when taken within 72 hours of unprotected sex. Taking it as soon as possible maximizes its effectiveness in preventing pregnancy by delaying or inhibiting ovulation. Choice B is incorrect as levonorgestrel can be used even if the person is on an oral contraceptive. Choice C is incorrect because a delayed period does not necessarily indicate pregnancy; a pregnancy test should be taken if there are other signs of pregnancy. Choice D is incorrect because levonorgestrel is only effective for a short period after taking it and does not provide long-term protection against pregnancy.