Nokea
Which of the following is a correctly stated nursing diagnosis for a client with abruptio placentae?
- A. Infection related to obstetrical trauma.
- B. Potential for fetal injury related to abruptio placentae.
- C. Potential alteration in tissue perfusion related to depletion of fibrinogen.
- D. Fluid volume deficit related to bleeding.
Correct Answer: D
Rationale: abruptio placenta is premature separation of a normally implanted placenta leading to hemorrhage; fluid volume deficit is a major nursing concern with these clients
You may also like to solve these questions
The first action that the nurse should take if she finds the client has an O2 saturation of 68% is:
- A. Elevate the head
- B. Recheck the O2 saturation in 30 minutes
- C. Apply oxygen by mask
- D. Assess the heart rate
Correct Answer: C
Rationale: An O2 saturation of 68% indicates severe hypoxemia, requiring immediate oxygen administration.
The physician has made a diagnosis of 'shaken child' syndrome for a 13-month-old who was brought to the emergency room after a reported fall from his highchair. Which finding supports the diagnosis of 'shaken child' syndrome?
- A. Fracture of the clavicle
- B. Periorbital bruising
- C. Retinal hemorrhages
- D. Fracture of the humerus
Correct Answer: C
Rationale: Retinal hemorrhages are a hallmark of shaken baby syndrome due to the shearing forces from violent shaking causing bleeding in the retina.
A client with preeclampsia has been receiving an infusion containing magnesium sulfate for a blood pressure that is 160/80; deep tendon reflexes are 1 plus, and the urinary output for the past hour is 100 mL. The nurse should:
- A. Continue the infusion of magnesium sulfate while monitoring the client's blood pressure
- B. Stop the infusion of magnesium sulfate and contact the physician
- C. Slow the infusion rate and turn the client on her left side
- D. Administer calcium gluconate IV push and continue to monitor the blood pressure
Correct Answer: A
Rationale: The parameters (BP 160/80, 1+ reflexes, 100 mL urine output) are within acceptable limits, so the infusion should continue.
The physician has ordered cultures for cytomegalovirus (CMV). Which statement is true of the collection of cultures for cytomegalovirus?
- A. Stool cultures are preferred for definitive diagnosis.
- B. Pregnant caregivers may obtain cultures.
- C. Collection of one specimen is sufficient.
- D. Accurate diagnosis depends on fresh specimens.
Correct Answer: D
Rationale: Fresh specimens are critical for accurate CMV culture results, as the virus is labile and degrades quickly.
A burn client's care plan reveals an expected outcome of no localized or systemic infection. Which assessment by the nurse supports this outcome?
- A. Wound culture results that show minimal bacteria
- B. Cloudy, foul-smelling urine output
- C. White blood cell count of 14,000
- D. Temperature of 101°F
Correct Answer: A
Rationale: Minimal bacteria in wound cultures supports the absence of localized infection, aligning with the care plan's goal.