Nokea
Which of the following instructions should the nurse include in the teaching?
- A. Take your temperature immediately after waking and before getting out of bed.
- B. Measure your temperature in the afternoon for the most accurate reading.
- C. A rise in body temperature of at least 2°F indicates ovulation has occurred.
- D. Use a standard digital thermometer for the most precise results.
Correct Answer: A
Rationale: The correct answer is A: Take your temperature immediately after waking and before getting out of bed. This instruction is part of basal body temperature monitoring for ovulation tracking. Body temperature is lowest upon waking and increases after ovulation, so taking the temperature before getting out of bed provides the most accurate baseline measurement. Choice B is incorrect because afternoon temperatures can fluctuate due to various factors. Choice C is incorrect as a rise of at least 0.4°F, not 2°F, indicates ovulation. Choice D is incorrect because a basal body temperature thermometer is more appropriate for this purpose than a standard digital thermometer.
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The nurse is reviewing the client's medical record. Select 4 findings that indicate a potential prenatal complication.
- A. Urine protein
- B. Fetal activity
- C. Blood pressure
- D. Urine ketones
- E. Respiratory rate
- F. Report of headache
- G. Gravida/parity
Correct Answer: A,C,F,G
Rationale: The correct answers (A, C, F, G) indicate potential prenatal complications. Urine protein (A) suggests preeclampsia, a serious condition characterized by high blood pressure (C) and proteinuria. Headaches (F) can also be a sign of preeclampsia. Gravida/parity (G) provides important obstetric history, identifying high-risk pregnancies. Fetal activity (B) and respiratory rate (E) are not specific to prenatal complications. Urine ketones (D) may indicate dehydration but not necessarily a prenatal complication.
The nurse should identify the cardiac rhythm as which of the following?
- A. Ventricular asystole
- B. Second-degree heart block
- C. Sinus Tachycard
- D. Atrial fibrillation
Correct Answer: D
Rationale: The correct answer is D: Atrial fibrillation. In atrial fibrillation, the atria quiver instead of contracting effectively, leading to an irregular and rapid heart rate. This can be identified on an ECG by the absence of distinct P waves and irregular R-R intervals. Ventricular asystole (A) is the absence of ventricular contractions, second-degree heart block (B) is characterized by intermittent conduction block between the atria and ventricles, and sinus tachycardia (C) is a regular rapid heart rate originating from the sinus node.
The provider has admitted the client to the inpatient obstetrics unit and written prescriptions based on the client's condition. The action the nurse should take first is------followed by ----------
- A. evaluating the fetal heart rate tracing
- B. monitoring urine output
- C. Checking the client's blood pressure
- D. administering labetalol
- E. Starting the continuous IV infusion
- F. inserting an indwelling urinary catheter
Correct Answer: C,D
Rationale: The correct first action is to check the client's blood pressure (Choice C) as it is essential to assess the client's immediate physiological status. High blood pressure in obstetric patients can lead to severe complications. Administering labetalol (Choice D) is the next step if the blood pressure is elevated, as it is a commonly used medication to manage hypertension in pregnancy. Choices A, B, E, and F are important interventions but should be prioritized after addressing the client's blood pressure as they are not directly related to the immediate risk of hypertensive crisis.
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing.
- A. Ensure that client has intake of at least 200mL/hr
- B. Initiate contact precautions
- C. Prepare client for light therapy
- D. Sickle cell crisis
- E. Psoriasis
- F. Osteomyelitis
Correct Answer: B,C
Rationale: Increased fluid intake and contact precautions are essential for managing systemic lupus erythematosus.
Which of the following findings should the nurse expect?
- A. Reduce right sided breath sounds
- B. Inter coastal retractions
- C. High pitched strider
- D. Paradoxical chest movement
Correct Answer: A
Rationale: The correct answer is A: Reduced right-sided breath sounds. This finding suggests a potential pneumothorax on the right side, where air leaks into the pleural space causing lung collapse and decreased breath sounds. Intercostal retractions (B) indicate increased work of breathing, likely due to respiratory distress but not specific to a pneumothorax. High-pitched stridor (C) is a sign of upper airway obstruction, not typically seen with pneumothorax. Paradoxical chest movement (D) is seen in flail chest, not characteristic of pneumothorax.