School-age child with heart failure taking furosemide
A nurse is assessing a school-age child who has heart failure and is taking furosemide. Which of the following findings should the nurse identify as an indication that the medication is effective?
Rationale:
A decrease in peripheral edema indicates that furosemide is effective. Furosemide is a loop diuretic that promotes fluid excretion, reducing fluid overload in heart failure patients. A reduction in edema shows successful removal of excess fluid, alleviating symptoms and improving cardiac function by decreasing workload on the heart and preventing complications related to fluid retention.
B: Decrease in cardiac output suggests worsening heart function, not improvement; furosemide aims to reduce fluid, not lower cardiac output.
C: Increase in venous pressure reflects fluid overload or worsening heart failure, contrary to furosemide’s purpose of lowering pressure by diuresis.
D: Increase in potassium levels is unlikely because furosemide commonly causes potassium loss, potentially leading to hypokalemia rather than elevation.
None specified.
The maternity nurse understands that vascular volume increases 40% to 45% during pregnancy to:
Rationale:
Vascular volume increases 40% to 45% during pregnancy to provide adequate perfusion of the placenta. This expansion supports enhanced blood flow necessary for delivering oxygen and nutrients to the developing fetus, ensuring proper fetal growth and development while maintaining maternal cardiovascular stability throughout gestation.
A: Compensate for decreased renal plasma flow does not align since renal plasma flow actually increases during pregnancy, facilitating waste elimination rather than requiring vascular volume compensation.
B: Prevent maternal and fetal dehydration overlooks that fluid retention primarily supports circulatory demands, not direct hydration status, which is regulated by other mechanisms including hormonal control.
D: Eliminate metabolic wastes of the mother mistakenly attributes vascular volume increase to waste removal, whereas waste elimination depends more on renal and hepatic functions, not blood volume expansion.
Postmature newborn
A nurse is preparing to assess a newborn who is postmature. Which of the following findings should the nurse expect? (Select all that apply)
Rationale:
Postmature newborns typically present with cracked, peeling skin due to prolonged exposure to amniotic fluid depletion. This skin change signifies advanced gestational age beyond term, reflecting the natural shedding and dryness caused by postmaturity. The peeling skin is a hallmark sign that helps distinguish postmature infants from those born at term or preterm, confirming fetal aging effects.
B: Short soft fingernails usually indicate prematurity, as nail growth is incomplete. Postmature infants tend to have longer, more developed nails reflecting extended gestation rather than the shorter, delicate nails seen in preterm newborns.
C: Primitive Moro reflexes are more prominent in preterm infants; postmature newborns generally exhibit well-developed or normal reflexes. The presence of delayed or absent Moro reflexes is not characteristic of postmaturity.
D: Abundant lanugo is a feature of premature infants, representing incomplete fetal development. Postmature newborns typically have decreased or absent lanugo due to prolonged gestation and further maturation.
E: Vernix caseosa is thick and abundant in preterm infants but tends to be minimal or absent in postmature newborns, as it is normally shed late in gestation.
Parents of a newborn about caring for the umbilical cord stump.
Which of the following instructions should the nurse include?
Rationale:
Give the newborn a sponge bath until the cord stump falls off. This instruction helps keep the umbilical cord stump dry, which is essential for proper healing and preventing infection. Sponge baths avoid submerging the stump in water, reducing moisture accumulation that could delay healing or promote bacterial growth, ensuring the stump dries and detaches naturally.
B: Wrap the cord in petroleum jelly gauze. Applying petroleum jelly can trap moisture around the stump, increasing the risk of infection and delaying natural drying and detachment. This practice is not recommended for umbilical cord care.
C: Wash the cord daily with mild soap and water. Frequent washing with soap may irritate the sensitive cord area or introduce bacteria, potentially causing infection. The stump should be kept dry rather than cleaned excessively with soap.
D: Cover the cord with the diaper. Covering the stump can trap moisture and urine, creating a damp environment that fosters bacterial growth and infection. The diaper should be folded below the stump to keep it exposed to air.
Two days after delivery, a postpartum client prepares for discharge. What should the nurse teach her about lochia flow?
Rationale:
Lochia normally lasts for about 21 days, and changes from a bright red, to pinkish brown, to creamy white.
This option accurately describes the typical duration and progression of lochia color changes postpartum, reflecting the normal healing process of the uterus. It aligns with established clinical guidelines, indicating a gradual transition through rubra, serosa, and alba phases over approximately three weeks.
A: Lochia does change color but goes from lochia rubra (bright red) on days 1-3, to lochia serosa (pinkish brown) on days 4-9, to lochia alba (creamy white) days 10-21. This is overly specific and restrictive regarding day ranges, which can vary among individuals.
B: Numerous clots are abnormal and should be reported to the physician. This statement is misleading as small clots can be normal; only large or frequent clots coupled with other symptoms warrant concern.
C: Saturation of the perineal pad is considered abnormal and may indicate postpartum hemorrhage. While heavy bleeding is concerning, normal lochia flow can sometimes saturate a pad, especially soon after delivery, so context matters for evaluation.
A nurse is caring for a newborn who has macrosomia and whose mother has diabetes mellitus.
Which of the following newborn complications should the nurse recognize as the priority focus of care?
Rationale:
Hypoglycemia is the priority focus of care for a newborn with macrosomia and a diabetic mother. Infants born to diabetic mothers are at high risk for hypoglycemia due to fetal hyperinsulinemia, which causes rapid glucose utilization after birth. Early detection and management prevent serious neurological damage, making hypoglycemia the critical condition to monitor immediately after delivery.
A: Hypomagnesemia relates to low magnesium levels but is less common and less immediately threatening in infants of diabetic mothers compared to hypoglycemia, making it a lower priority for initial care focus.
B: Hyperbilirubinemia involves elevated bilirubin causing jaundice, which develops later and is not the immediate critical concern in infants of diabetic mothers post-delivery.
C: Hypocalcemia involves low calcium levels, which can occur but usually presents after hypoglycemia and is less immediately life-threatening in the newborn from a diabetic mother.
A client who is at 34 weeks of gestation and at risk for placental abruption.
The nurse recognizes that which of the following is the most common risk factor for a placental abruption?
Rationale:
Maternal hypertension is the most common risk factor for placental abruption.
Hypertension causes vascular damage and increased pressure in placental blood vessels, which can lead to premature separation of the placenta. This condition disrupts oxygen and nutrient supply to the fetus and increases the risk of bleeding, making it the predominant contributor to placental abruption in pregnancy.
A: Maternal cigarette smoking contributes to vascular constriction but is less frequently linked to abruptions. It primarily affects fetal growth rather than placental separation.
B: Maternal cocaine use causes vasospasm and abruptions but is less common and more associated with acute, severe cases than general hypertensive risks.
D: Maternal battering involves trauma that can cause abruptions but is not as prevalent or consistent a risk factor as hypertension in placental abruption cases.
A nurse is assessing a client who is receiving a blood transfusion. The nurse notes lung crackles, hypoxia, and distended neck veins.
Which of the following actions should the nurse take? (Select all that apply.)
Rationale:
Stop the transfusion. Placing the client in high-Fowler’s position and administering oxygen are appropriate actions. These interventions address symptoms of transfusion-associated circulatory overload (TACO), such as lung crackles, hypoxia, and distended neck veins. Stopping the transfusion prevents further volume overload while oxygen improves hypoxia, and high-Fowler’s position facilitates breathing and reduces venous return, easing cardiac workload.
B: Obtain a prescription for a diuretic. Immediate diuretic administration is not the first action; stopping the transfusion and stabilizing respiratory status take priority before medication orders.
D: Administer epinephrine to the client. Epinephrine is used for anaphylactic reactions, not for circulatory overload symptoms like lung crackles and distended neck veins.
A client prescribed quetiapine 50 mg PO divided equally every 12 hours for 3 days
A provider prescribes quetiapine 50 mg PO divided equally every 12 hours for 3 days. Available is quetiapine 25 mg tablets. How many tablets should the nurse administer per dose on day 3?
Rationale:
One tablet should be administered per dose on day 3.
The prescription requires 50 mg divided equally every 12 hours, meaning 25 mg per dose. Since each tablet is 25 mg, one tablet per dose meets the prescribed amount accurately. Administering the correct dose ensures therapeutic effectiveness and patient safety over the 3-day period.
A: 2 tablets Each tablet is 25 mg, so 2 tablets equal 50 mg per dose, doubling the prescribed 25 mg dose, risking overdose and adverse effects.
C: 3 tablets Three tablets total 75 mg per dose, exceeding the prescribed amount by 50%, increasing potential toxicity and deviating from the provider's instructions.
D: 4 tablets Four tablets equal 100 mg per dose, which is quadruple the prescribed dosage, posing serious safety risks and not aligning with the divided dosing schedule.
A nurse has been assigned to assess a pregnant client for abruptio placenta.
For which classic manifestation of this condition should the nurse assess?
Rationale:
Knife-like' abdominal pain with vaginal bleeding is the classic manifestation of abruptio placenta. This condition involves premature separation of the placenta, causing sharp, severe abdominal pain and bleeding. The pain is sudden and intense, reflecting placental detachment, while bleeding varies but often accompanies the painful symptoms, distinguishing it from other pregnancy complications with different clinical presentations.
A: Generalized vasospasm describes widespread blood vessel constriction, not specific to abruptio placenta, and does not capture the hallmark symptoms of pain and bleeding unique to this condition.
B: Painless bright red vaginal bleeding typically signals placenta previa, contrasting with abruptio placenta’s painful bleeding. The absence of pain differentiates these distinct obstetric emergencies.
D: Increased fetal movement is unrelated to abruptio placenta and does not serve as a diagnostic indicator; fetal distress often decreases movement in placental abruption cases.
A woman hospitalized with severe preeclampsia is being treated with hydralazine
A woman hospitalized with severe preeclampsia is being treated with hydralazine to control blood pressure. Which finding would lead the nurse to suspect that the client is having an adverse effect associated with this drug?
Rationale:
Tachycardia is the finding that would lead the nurse to suspect an adverse effect of hydralazine.
Hydralazine can cause reflex tachycardia as a compensatory response to vasodilation and lowered blood pressure. This increased heart rate is a known side effect, signaling that the drug is affecting cardiovascular function and requires careful monitoring to prevent further complications in preeclamptic patients.
A: Gastrointestinal bleeding Hydralazine is not commonly linked to gastrointestinal bleeding; this symptom more often arises from anticoagulants or NSAIDs, not antihypertensive vasodilators like hydralazine.
B: Sweating Sweating is not a typical adverse effect of hydralazine; it is more associated with fever, infections, or autonomic nervous system disorders rather than this specific antihypertensive medication.
D: Blurred vision Blurred vision is unrelated to hydralazine’s pharmacologic profile and usually indicates neurologic or ocular issues, not an adverse reaction to this vasodilator drug.
A client who received a positive test result for chlamydia
A nurse in a community clinic is counseling a client who received a positive test result for chlamydia. Which of the following statements should the nurse provide?
Rationale:
This infection is treated with one dose of azithromycin. Azithromycin is a recommended single-dose antibiotic for uncomplicated chlamydia infections, ensuring effective treatment and patient compliance. The nurse should inform the client about this standard therapy to promote cure and prevent complications. This guidance aligns with clinical protocols for managing chlamydia in community health settings efficiently.
A: If your sexual partner has no symptoms, no medication is needed. Sexual partners require treatment regardless of symptoms to prevent reinfection and transmission, as chlamydia often presents asymptomatically.
C: You need to return in 6 months for retesting. Retesting is typically advised after 3 months to ensure eradication and detect reinfection, not after 6 months.
D: You have to avoid sexual relations for 3 days. Abstinence is recommended until treatment completion and symptom resolution, usually about 7 days, to prevent spread.
A pregnant woman compulsively craves ice
Assessment of a pregnant woman reveals that she compulsively craves ice. The nurse documents this finding as
Rationale:
The nurse documents the compulsive craving of ice in a pregnant woman as pica. Pica is characterized by the persistent ingestion of non-nutritive substances, often linked to nutritional deficiencies like iron deficiency anemia during pregnancy. This behavior is well-documented in clinical settings and requires assessment to address possible underlying health issues and ensure maternal and fetal well-being throughout gestation.
A: linea nigra refers to a dark vertical line appearing on the abdomen during pregnancy, unrelated to behavioral cravings or consumption of non-food substances.
C: ballottement describes a physical examination technique to detect fetal movement by tapping the cervix, not associated with any cravings or eating behaviors.
D: quickening signifies the first fetal movements felt by the mother, which is a physiological sensation and not linked to compulsive eating or craving patterns.
The nursing instructor is preparing to illustrate the various changes between the nonpregnant and pregnant female bodies.
The instructor should point out that the blood volume in the pregnant woman can increase by what percentage?
Rationale:
Blood volume in the pregnant woman can increase by 40% to 45%. This significant rise supports the greater metabolic demands and fetal development by enhancing oxygen and nutrient transport. It also helps accommodate the expanded vascular system and prepares the mother’s body for potential blood loss during delivery, ensuring adequate circulation and fetal well-being throughout pregnancy.
A: 20% to 25% underestimates the physiological changes; the increase must be more substantial to meet pregnancy demands.
C: 50% to 55% exaggerates the rise beyond typical clinical observations and standard physiological adaptations during pregnancy.
D: 30% to 35% is insufficient to account for the extensive cardiovascular adjustments necessary for fetal support and maternal health.
Client at 38 weeks of gestation with continuous abdominal pain, vaginal bleeding, and cocaine use history
A nurse is caring for a client who is at 38 weeks of gestation and is experiencing continuous abdominal pain and vaginal bleeding. The client has a history of cocaine use. The nurse should identify that the client is likely experiencing which of the following complications?
Rationale:
Abruptio placentae.
Abruptio placentae involves premature separation of the placenta, causing continuous abdominal pain and vaginal bleeding, especially in late pregnancy. Cocaine use significantly increases the risk by causing vasoconstriction and placental ischemia. These clinical signs at 38 weeks strongly suggest abruptio placentae, which can lead to fetal distress and requires immediate medical attention to prevent complications for both mother and baby.
B: Hydatidiform mole involves abnormal trophoblastic proliferation and usually presents with excessive uterine enlargement and absence of fetal heart tones, differing from the acute pain and bleeding seen here.
C: Preterm labor occurs before 37 weeks and typically presents with regular contractions and cervical changes, not continuous pain and significant bleeding at term.
D: Placenta previa causes painless vaginal bleeding rather than continuous abdominal pain, making it inconsistent with the client’s symptoms and cocaine-related risks.
Newborn receiving a vitamin K injection
A parent asks the nurse why the newborn is getting a vitamin K injection in the birth room. The nurse explains that the injection is necessary because:
Rationale:
Newborns receive a vitamin K injection because vitamin K is needed for coagulation, and the newborn does not produce enough vitamin K. Vitamin K facilitates blood clotting by activating clotting factors, preventing serious bleeding. Newborns naturally have low vitamin K levels due to limited placental transfer and sterile intestines lacking vitamin K-producing bacteria, making supplementation essential immediately after birth.
A: Newborns are prone to hypoglycemia, and vitamin K helps maintain a steady blood glucose level. This confuses vitamin K’s role with glucose regulation, which involves different metabolic processes and hormones, not vitamin K.
C: The birthing parent was febrile at the time of birth and prophylactic vitamin K is necessary. Fever in the parent does not influence newborn vitamin K administration; the injection is standard regardless of maternal fever status.
D: Newborns have deficient levels of prothrombin. While prothrombin is a clotting factor, the deficiency arises from low vitamin K, not direct prothrombin shortage; vitamin K is the critical factor supplemented here.
A nurse is planning care for a client who is 1 hr postpartum and has peripartum cardiomyopathy.
Which of the following actions should the nurse plan to take?
Rationale:
Restrict daily oral fluid intake.
This action is essential because peripartum cardiomyopathy involves heart failure, where fluid overload can exacerbate symptoms and worsen cardiac function. Limiting fluid intake helps prevent volume overload, reduces strain on the heart, and supports optimal cardiac output and oxygenation in the immediate postpartum period, promoting better recovery and stability for the client.
B: Administer an IV bolus of lactated Ringer's. This could increase fluid volume rapidly, potentially worsening heart failure symptoms by causing fluid overload and increasing cardiac workload in a client with compromised heart function.
C: Assess blood pressure twice daily. Blood pressure monitoring alone is insufficient; more frequent assessments and comprehensive monitoring are crucial to detect rapid changes in cardiac status postpartum.
D: Obtain a prescription for misoprostol. Misoprostol is used to manage postpartum hemorrhage, not directly related to the cardiac management needed for peripartum cardiomyopathy.
A nurse is aware that which type of heat loss in newborns occurs through direct contact with a cooler surface?
Rationale:
Direct Answer: Conduction is the type of heat loss in newborns that occurs through direct contact with a cooler surface.
Correct Option Explanation: Conduction involves the transfer of heat from the newborn’s body directly to a cooler object or surface through physical contact. This process is significant in clinical settings, such as when an infant lies on a cold mattress or examination table, resulting in rapid heat loss by the newborn to the cooler surface beneath them.
B: Evaporation involves heat loss through the conversion of liquid on the skin into vapor, not direct surface contact, making it unrelated to heat transfer via touching cooler objects.
C: Radiation refers to heat transfer through infrared rays to cooler surrounding objects without contact, differing from conduction’s requirement for direct physical touch.
D: Convection involves heat loss through air currents moving around the newborn, not through direct contact with a cooler surface, distinguishing it from conduction’s mechanism.
Client at 8 weeks of gestation
A nurse is providing teaching to a client who is at 8 weeks of gestation. Which of the following statements by the client indicates a need for further teaching?
Rationale:
The statement "I need to avoid exercising throughout my pregnancy" indicates a need for further teaching. Regular, moderate exercise is generally recommended during pregnancy unless contraindicated, as it promotes maternal health and fetal well-being. Avoiding all exercise is unnecessary and can lead to negative physical and psychological outcomes. Proper guidance encourages safe physical activity tailored to the client’s condition.
A: I should expect to have white vaginal discharge during my pregnancy. This is accurate since increased vaginal discharge is a common and normal physiological change during pregnancy due to hormonal fluctuations and increased blood flow.
B: I can continue to drink one cup of coffee each day. Moderate caffeine intake is considered safe during pregnancy, with guidelines generally recommending limiting caffeine to less than 200 mg daily to avoid adverse fetal effects.
D: I should take my prenatal vitamin with a full glass of water. Taking prenatal vitamins with water aids absorption and helps prevent gastrointestinal discomfort, making this statement a correct and appropriate practice for pregnant clients.
A nurse is assessing a newborn who is 4 hr old.
Which of the following findings should the nurse identify as the priority to report to the provider?
Rationale:
Forward and lateral positioning of the ears should be identified as the priority finding to report to the provider. This abnormal ear placement can indicate underlying congenital anomalies or chromosomal abnormalities requiring prompt evaluation. Early detection facilitates timely intervention and further diagnostic testing, ensuring appropriate management of potential systemic issues associated with ear malposition in the newborn.
A: Bluish discoloration of the hands and feet represents acrocyanosis, a common and transient condition in newborns, generally not requiring urgent reporting as it often resolves without intervention.
B: Overlapping of the cranial bones is typically a normal finding related to birth molding during delivery and usually resolves spontaneously without necessitating immediate provider notification.
D: Small, distended white sebaceous glands on the face are known as milia, a benign and self-limiting condition frequently observed in newborns, not necessitating urgent concern or reporting.
Parent of a newborn.
A nurse is teaching the parent of a newborn about car seat safety. Which of the following statements should the nurse make?
Rationale:
You should keep the car seat rear-facing until your baby is at least 2 years old. This recommendation aligns with safety guidelines that emphasize rear-facing seats offer better head, neck, and spine protection for infants and toddlers during collisions, significantly reducing injury risk. The age threshold ensures enhanced safety during the most vulnerable developmental stages of a child’s musculoskeletal system.
B: Position the retainer clip over the upper part of your baby's abdomen places pressure on vital organs, increasing injury risk. The clip should be at the armpit level to properly secure the child and distribute forces safely during impact.
C: You should place your baby in the car seat at a 90-degree angle risks airway obstruction and insufficient head support. Newborns require a reclined position to maintain an open airway and prevent slumping, which can cause breathing difficulties.
D: Place the shoulder harness straps in the slots an inch above your baby's shoulders fits toddlers but not newborns. For infants, harness straps should be at or below shoulder level to ensure a snug fit and optimal restraint during travel.
Client in labor with contractions 4 min apart
A nurse receives report about a client who is in labor and is having contractions 4 min apart. Which of the following patterns should the nurse expect on the fetal monitoring tracing?
Rationale:
Contractions that last for 60 seconds each with a 3-min rest between contractions. This pattern matches contractions occurring every 4 minutes, with each contraction lasting about 60 seconds, leaving approximately 3 minutes of rest. It aligns with normal labor progression, allowing adequate fetal oxygenation and maternal recovery between contractions, which is vital for safe labor monitoring and fetal well-being.
A: Contractions that last 45 seconds each with a 3 min rest between contractions. This duration underestimates contraction length, not reflecting typical 60-second contractions seen during active labor with 4-minute intervals.
C: Contractions that last for 60 seconds each with a 4-min rest between contractions. A 4-minute rest contradicts the given 4-minute contraction interval, making the total cycle longer than the stated contraction frequency.
D: A contraction that lasts 4 min followed by a period of relaxation. A 4-minute-long contraction is excessively prolonged, risking fetal distress and is inconsistent with normal labor contraction patterns.
A nurse is preparing to administer a controlled substance to a client for pain management.
Which of the following actions should the nurse take?
Rationale:
The nurse should ask a second nurse to record her signature when wasting any unused portion of the controlled substance. This action ensures accountability and compliance with legal regulations by verifying the disposal of the controlled substance through witness confirmation, preventing misuse or diversion, and maintaining accurate documentation for controlled drug handling protocols within healthcare settings.
A: Placing the wasted portion in the sharp's container risks contamination and violates proper disposal guidelines for controlled substances, which require specific procedures to prevent misuse and ensure safety.
B: Reporting discrepancies after administration is important but does not address immediate verification and documentation needed during the medication wasting process.
C: Verifying the count after removal is necessary but does not replace the requirement for a witness signature to document the wasting of unused medication portions.
Newborn immediately following birth
A nurse is assisting with the care of a newborn immediately following birth. Which of the following medications should the nurse anticipate administering? (Select all that apply.)
Rationale:
The nurse should anticipate administering the Hepatitis B immunization, Vitamin K injection, and antibiotic ointment to both eyes immediately following birth. Hepatitis B vaccine protects against early infection, Vitamin K prevents bleeding disorders by aiding clotting, and antibiotic ointment prevents neonatal eye infections. These interventions are standard newborn care to ensure immediate protection and reduce infection risks.
B: Haemophilus influenza type b immunization (Hib) is not given at birth but later in infancy, typically starting at 2 months, so it is not appropriate immediately post-delivery.
C: Lidocaine gel to the umbilical stump is not a routine practice; umbilical care usually involves keeping the area clean and dry without topical anesthetics.
Newborn who is 48 hours old with maternal methadone use
A nurse is assessing a newborn who is 48 hours old and has a maternal history of methadone use during pregnancy. Which of the following manifestations should the nurse identify as an indication of neonatal abstinence syndrome?
Rationale:
Excessive high-pitched cry indicates neonatal abstinence syndrome. This symptom reflects central nervous system irritability commonly seen in newborns withdrawing from opioids like methadone. It signifies heightened neurological excitability and distress, distinguishing it from normal infant crying patterns. Early recognition helps initiate appropriate supportive care and monitoring to manage withdrawal symptoms effectively and reduce complications associated with neonatal abstinence syndrome.
A: Hyporeactivity represents decreased responsiveness, which contrasts with the hyperactivity typical of neonatal abstinence syndrome, making it an unlikely indicator of opioid withdrawal in newborns.
C: Acrocyanosis involves peripheral bluish discoloration and is generally a benign circulatory finding, unrelated to the neurological hyperactivity seen in neonatal abstinence syndrome.
D: Respiratory rate of 50/min falls within normal newborn parameters and does not specifically signify withdrawal symptoms or neonatal abstinence syndrome manifestations.
A client who has pre-gestational diabetes mellitus
A nurse is caring for a client who has pre-gestational diabetes mellitus. Which of the following clinical findings should indicate to the nurse the client has hyperglycemia?
Rationale:
Increased urination indicates hyperglycemia in a client with pre-gestational diabetes mellitus. Elevated blood glucose levels cause osmotic diuresis, leading to frequent urination as the kidneys attempt to excrete excess glucose. This symptom is a classic sign of hyperglycemia and helps differentiate it from hypoglycemia, where urination typically does not increase.
A: Dizziness often relates to hypoglycemia or other conditions, not specifically hyperglycemia, making it an unreliable indicator of elevated blood glucose levels.
C: Sweating generally associates with hypoglycemia due to autonomic nervous system activation, contrasting with hyperglycemia where sweating is not a prominent feature.
D: Double vision can result from various causes like neurological issues, but it is not a primary or direct symptom of hyperglycemia in diabetes management.
A nurse is reviewing the laboratory report for a client who is in active labor. The client tested positive for group B streptococcus B-hemolytic.
Which of the following medications should the nurse plan to administer to the client?
Rationale:
Ampicillin should be administered to the client who tested positive for group B streptococcus. Ampicillin is a penicillin-class antibiotic effective against group B streptococcus and is the standard treatment during labor to prevent neonatal infection. It is preferred due to its safety profile, efficacy in reducing early-onset GBS disease, and widespread clinical use in intrapartum antibiotic prophylaxis protocols.
A: Doxycycline is not typically used for group B streptococcus intrapartum prophylaxis and has limited efficacy against this bacterium in labor settings.
B: Cefotetan, while a cephalosporin, is less commonly chosen for GBS prophylaxis during labor compared to ampicillin due to spectrum and clinical guidelines.
D: Fluconazole is an antifungal medication and does not target bacterial infections like group B streptococcus, making it unsuitable for this indication.
A nurse is caring for a client who is at 36 weeks of gestation and who has suspected placenta previa. The client is admitted with bright red vaginal bleeding and no abdominal pain.
Which of the following actions should the nurse take?
Rationale:
Administer betamethasone intramuscularly to promote fetal lung maturity in anticipation of potential preterm delivery due to placenta previa complications.
C: Betamethasone accelerates fetal lung development, reducing respiratory distress risk if early delivery becomes necessary. Placenta previa often leads to preterm birth, making corticosteroid administration essential for neonatal outcomes.
A: Obtain a culture of the vaginal discharge risks exacerbating bleeding and infection; vaginal bleeding in placenta previa is not typically infectious in origin, so this action is inappropriate.
B: Insert an indwelling urinary catheter is unnecessary unless urinary retention occurs; it does not address bleeding management or fetal lung maturity in placenta previa cases.
D: Perform a vaginal examination can provoke severe bleeding and fetal compromise in placenta previa, so it is contraindicated until placenta location is confirmed by ultrasound.
A nurse is caring for a toddler who is in an oxygen tent. Which of the following actions should the nurse take in order to promote comfort while maintaining the child's safety?
Rationale:
Changing the bedding and the child's clothing frequently or as often as needed promotes comfort while maintaining safety in an oxygen tent. Frequent changes prevent skin irritation and moisture buildup, which can cause discomfort or infection. Clean, dry linens and clothing also reduce the risk of spreading bacteria, ensuring a hygienic environment essential for the child’s health and safety during oxygen therapy.
A: Give the child a stuffed animal and car with rubber wheels to play with. These items may not be safe or easily sanitized in an oxygen-rich environment, increasing infection risk or fire hazards.
B: "Give the child a stuffed animal and car with rubber wheels to play with." This duplicate option repeats safety concerns about non-sanitizable toys and fire risks in oxygen tents.
D: "Tuck the bottom of the tent under the mattress on three sides, leaving one side open so the child can look out." This compromises the tent’s oxygen concentration and safety by not sealing all sides properly.
A woman at 32 weeks' gestation with a fundal height measurement of 26 centimeters.
A woman is at 32 weeks' gestation. Her fundal height measurement at this clinic appointment is 26 centimeters. After reviewing her ultrasound results, the health care provider asks the nurse to schedule the client for a series of ultrasounds to be done every 2 weeks. The nurse should ensure that the client understands that the main purpose for this is to:
Rationale:
Direct Answer: The main purpose of scheduling ultrasounds every 2 weeks is to monitor fetal growth.
Correct Option Explanation: Monitoring fetal growth is essential when fundal height measurements are smaller than expected, as in this case. Serial ultrasounds help detect intrauterine growth restriction or other growth abnormalities by tracking consistent growth patterns over time. This allows timely intervention to improve both maternal and fetal outcomes by ensuring appropriate fetal development.
A: Rule out a suspected hydatidiform mole is unrelated because this diagnosis typically presents with excessive uterine size, not decreased fundal height, and requires different diagnostic approaches.
B: Assess for congenital anomalies does not necessitate repeated ultrasounds every two weeks; anomalies are usually identified during a detailed anomaly scan once in mid-pregnancy.
C: Determine fetal presentation involves a single assessment closer to term and does not require frequent ultrasounds, making this choice irrelevant for serial measurements.
The labor and delivery nurse is caring for a client in active labor. The nurse notes the fetal heart rate baseline is 175 bpm, moderate variability. Accelerations are absent and no decelerations noted.
How should the nurse describe this tracing to the medical provider?
Rationale:
The nurse should describe this tracing as Category II. Category II tracings include fetal heart rates outside the normal baseline range of 110-160 bpm, such as 175 bpm, with moderate variability and absent accelerations, indicating an indeterminate pattern requiring continued observation and assessment but not immediate intervention.
A: Category I represents normal baseline heart rate (110-160 bpm) with moderate variability and presence of accelerations, which does not match the elevated baseline of 175 bpm seen here.
C: Category III involves abnormal patterns like absent variability with recurrent decelerations or bradycardia, which this tracing lacks.
D: Category IV is not a recognized category in fetal heart rate monitoring classifications and has no clinical relevance.
A client who might be pregnant
A nurse in a prenatal clinic is caring for a client who states that she might be pregnant because she feels the baby moving. How does the nurse classify this statement by the client?
Rationale:
This is a presumptive sign of pregnancy.
Presumptive signs are subjective indicators reported by the client, such as feeling fetal movement, which suggest pregnancy but are not definitive. These signs can be influenced by other conditions and do not provide absolute confirmation. The client’s perception of fetal movement fits this category, as it relies on personal experience rather than objective clinical evidence.
B: This is a positive sign of pregnancy. Positive signs require objective evidence like fetal heartbeat or ultrasound, not subjective sensations, so feeling the baby move does not meet this stringent criterion.
C: This is a probable sign of pregnancy. Probable signs are objective findings like uterine enlargement, which differ from the client’s personal report of fetal movement, making this option unsuitable.
D: This is a potential sign of pregnancy. The term “potential” is not standard in pregnancy classifications, and the client’s feeling does not align with recognized clinical terminology.
A nurse is caring for a client who had a vaginal delivery 2 hr ago.
Which of the following actions should the nurse anticipate in the care of this client? (Select all that apply.)
Rationale:
Observe the lochia during palpation of fundus, administer methylergonovine maleate if uterus is boggy, document fundal height, and determine whether the fundus is midline. These actions are essential postpartum assessments and interventions to monitor uterine involution, prevent hemorrhage, and ensure the uterus is contracting properly after vaginal delivery, promoting client safety and recovery.
E: Massage a firm fundus is unnecessary since a firm fundus indicates proper contraction; massaging it could cause discomfort or trauma without clinical benefit in this situation.
A client who is 2 days postpartum following a vaginal delivery and reports constipation
A nurse is reviewing the chart of a client who is 2 days postpartum following a vaginal delivery and reports constipation. Which of the following findings should the nurse identify as a contraindication to the use of a suppository?
Rationale:
A third-degree perineal laceration is a contraindication to the use of a suppository. This type of laceration involves the anal sphincter, making suppository insertion potentially painful and harmful. It increases the risk of further tissue damage and infection, requiring careful management and avoidance of any rectal interventions that could disrupt healing or cause discomfort in this sensitive area.
A: Abdominal distention Abdominal distention does not directly affect the rectal mucosa or perineal healing, so it is not a contraindication to suppository use in postpartum clients. B: Afterpains Afterpains involve uterine contractions and are unrelated to rectal or perineal conditions; thus, they do not contraindicate suppository administration. C: Vaginal candidiasis Vaginal candidiasis affects the vaginal mucosa, not the rectal area, so it does not contraindicate the use of rectal suppositories in postpartum clients.
A nurse is assisting a client with breastfeeding her newborn.
The nurse should explain that which of the following reflexes will initiate sucking?
Rationale:
Rooting.
Rooting reflex triggers a newborn to turn the head and open the mouth when the cheek or mouth corner is touched, initiating sucking. This reflex helps the infant locate the nipple and begin feeding, making it essential for breastfeeding. It is a natural, automatic response present at birth that supports effective feeding behaviors.
B: Moro. Moro reflex involves a startle response to sudden stimuli, causing the infant to fling arms outward. It does not stimulate sucking or feeding behaviors, so it does not initiate breastfeeding.
C: Stepping. Stepping reflex causes the newborn to make walking motions when feet touch a surface. It relates to motor development and is unrelated to oral feeding or sucking initiation.
D: Babinski. Babinski reflex involves toe fanning when the sole is stroked, associated with neurological assessment rather than feeding. It does not affect sucking or breastfeeding initiation.
A group of clients in their first trimester
Which statement should the nurse include in the teaching about exercise during pregnancy?
Rationale:
Moderate exercise improves circulation.
Moderate exercise during pregnancy enhances blood flow, supporting oxygen and nutrient delivery to both mother and fetus. It helps maintain cardiovascular health, reduces pregnancy discomfort, and promotes overall well-being without posing risks associated with intense or inappropriate physical activities during the first trimester. This advice aligns with safe, evidence-based prenatal care guidelines.
B: Refrain from exercises that include stretching. Stretching is generally safe and beneficial during pregnancy, improving flexibility and reducing muscle tension. Avoiding all stretching is unnecessarily restrictive and not advised.
C: It is recommended to rest for 30 minutes before each new exercise. There is no standard guideline requiring a 30-minute rest before new exercises; gradual progression and listening to the body are preferred.
D: It is recommended to increase your weight-bearing exercises. Increasing weight-bearing exercises may pose risks by overstressing joints and ligaments, which are more vulnerable due to pregnancy-related hormonal changes.
An antepartal client at 35 weeks of gestation
A nurse is assessing the results of a nonstress test for an antepartal client at 35 weeks of gestation. Which of the following findings should indicate to the nurse the need for further diagnostic testing?
Rationale:
Irregular contractions of 10 to 20 seconds in duration that are not felt by the client should indicate the need for further diagnostic testing.
This finding suggests possible uterine irritability or preterm labor, which requires closer evaluation to prevent complications. The absence of client perception may delay timely intervention, making additional diagnostic testing crucial to assess fetal well-being and uterine activity accurately at 35 weeks gestation.
A: Three fetal movements perceived by the client in a 20-min testing period reflects normal fetal activity, indicating no immediate concern or need for further diagnostic testing.
B: No late decelerations with three uterine contractions suggest good fetal tolerance to contractions, signaling a reassuring fetal heart rate pattern without requiring additional tests.
C: An increase in fetal heart rate to 150/min above baseline lasting 10 seconds in response to movement represents a reactive nonstress test, indicating fetal well-being and no need for further evaluation.
Client at 12 weeks gestation with heartburn
A nurse in a prenatal clinic is caring for a client who is at 12 weeks gestation. The client is curious about the cause of her heartburn. Which of the following responses should the nurse provide?
Rationale:
Increased progesterone production causes decreased motility of smooth muscle. Progesterone relaxes smooth muscles, including the lower esophageal sphincter, leading to decreased motility and delayed gastric emptying, which allows stomach acid to reflux into the esophagus, causing heartburn in pregnancy. This hormonal effect explains the common gastrointestinal discomfort experienced in early pregnancy stages like 12 weeks gestation.
A: Pressure from the growing uterus displaces the stomach. At 12 weeks, the uterus is still relatively small and has not significantly displaced abdominal organs, so pressure is unlikely the main cause of heartburn at this stage.
C: Retained bile in the liver results in delayed digestion. Bile retention and liver-related digestion issues are not typical causes of heartburn in pregnancy; this option relates more to liver dysfunction or cholestasis, not acid reflux.
D: Increased estrogen production causes increased secretion of hydrochloric acid. Estrogen does not increase hydrochloric acid secretion; acid production typically remains the same or decreases, so this does not explain heartburn during pregnancy.
A nurse is performing an initial assessment of a newborn who was delivered with a nuchal cord. Which of the following clinical findings should the nurse expect?
Rationale:
Facial petechiae are a common clinical finding in newborns delivered with a nuchal cord. This occurs due to pressure on the face during delivery, causing small capillary hemorrhages. These pinpoint red or purple spots reflect minor trauma from venous congestion and impaired blood flow. They typically resolve without intervention and indicate transient delivery-related stress rather than a pathological condition.
A: Telangiectatic nevi are flat, pink patches often found on the nape of the neck, unrelated to nuchal cord delivery or trauma from birth. They represent benign vascular malformations, not caused by delivery complications.
C: Periauricular papillomas are benign skin growths near the ears, unrelated to the delivery process or nuchal cord complications. They do not result from mechanical pressure or vascular impairment during birth.
D: Erythema toxicum is a common newborn rash characterized by red blotches with small white or yellow papules, unrelated to trauma or pressure from a nuchal cord during delivery. It signifies a benign transient skin condition.
A client who has fibrocystic breast changes and is experiencing breast discomfort during menstruation
A nurse is providing teaching to a client who has fibrocystic breast changes and is experiencing breast discomfort during menstruation. Which of the following instructions should the nurse include?
Rationale:
Refrain from consuming alcohol.
Alcohol can exacerbate breast tenderness and fibrocystic changes by influencing hormone levels and fluid retention, which worsen discomfort during menstruation. Avoiding alcohol helps reduce these symptoms and promotes hormonal balance, providing relief from cyclical breast pain associated with fibrocystic breast changes. This advice aligns with managing symptoms conservatively and improving quality of life during menstrual cycles.
A: Increase your potassium intake Potassium does not specifically alleviate breast discomfort related to fibrocystic changes; it primarily regulates fluid balance and muscle function, making it less relevant for symptom management in this context.
B: Increase your fluid intake to 3 liters per day Excessive fluid intake is not directly linked to reducing breast discomfort from fibrocystic changes and could potentially increase swelling or discomfort due to fluid retention.
D: Limit your daily intake of fiber Fiber intake affects digestion and bowel health but has no significant impact on fibrocystic breast changes or menstrual breast discomfort, rendering this advice unrelated to symptom relief.
A nurse is teaching a new parent about breastfeeding her 2-week-old infant. Which of the following statements by the parent indicates an understanding of the teaching?
Rationale:
The more my baby is at the breast sucking, the more milk I will produce. This statement reflects the principle of supply and demand in breastfeeding, where frequent and effective suckling stimulates milk production. The infant’s sucking triggers hormonal responses that increase milk synthesis, ensuring adequate supply and promoting healthy breastfeeding practices in the early weeks of an infant’s life.
A: After 5 to 10 minutes when the breast is emptied, my baby should be removed from the breast. This is misleading as babies often need to feed until they naturally release the breast to ensure complete milk transfer and adequate nutrition. Premature removal can disrupt feeding patterns and reduce milk intake.
B: Manually expressing my milk will decrease my milk supply. Manual expression actually supports milk production by maintaining milk flow and relieving engorgement, especially if the baby is not nursing effectively or if supplementation is necessary.
C: My baby should always start on the same breast when feeding. Alternating breasts during feeding sessions is recommended to promote balanced milk production and prevent engorgement, making starting always on the same breast less appropriate.
A client who had a cerebral aneurysm rupture.
A nurse is monitoring a client who had a cerebral aneurysm rupture. Which of the following findings should the nurse identify as a manifestation of increased intracranial pressure?
Rationale:
Increased intracranial pressure is manifested by hypertension. Elevated pressure within the skull stimulates the body's compensatory mechanisms, leading to increased systemic blood pressure to maintain cerebral perfusion. This response helps ensure adequate oxygen and nutrient delivery to the brain despite the rising intracranial pressure, making hypertension a hallmark sign in clients with cerebral aneurysm rupture complications.
B: Tinnitus involves ear ringing and is unrelated to intracranial pressure changes, thus it does not signify increased pressure within the skull.
C: Hypotension reflects low blood pressure, which contradicts the typical hypertensive response seen with elevated intracranial pressure.
D: Tachycardia is an increased heart rate, which is not a primary indicator of intracranial pressure elevation and often decreases as pressure rises.
Four postpartum clients: 1 day ago needs Rh(D) immune globulin, 3 days ago reports breast fullness, 12 hours ago reports increased urinary output, 8 hours ago saturating a perineal pad every hour.
A nurse on a postpartum unit is receiving change-of-shift report for four clients. Which of the following clients should the nurse see first?
Rationale:
A client who gave birth 8 hours ago and is saturating a perineal pad every hour should be seen first. Rapid saturation indicates excessive postpartum bleeding, a potential emergency requiring immediate assessment to prevent hypovolemic shock. Prompt intervention can control hemorrhage and stabilize the client’s condition, prioritizing safety over other less urgent postpartum concerns presented by the other clients.
A: A client who gave birth 1 day ago and needs Rh(D) immune globulin involves scheduled medication administration without immediate risk. This situation lacks the urgency of active bleeding or acute symptoms requiring prompt assessment.
B: A client who gave birth 3 days ago and reports breast fullness reflects normal lactation onset. While uncomfortable, breast engorgement is not life-threatening and can be managed with routine nursing care and education.
C: A client who gave birth 12 hours ago and reports increased urinary output suggests normal diuresis after delivery. This physiological process does not indicate distress or complications demanding immediate nursing intervention.
A nurse is caring for a postpartum client in an outpatient setting
Exhibit1:
History and Physical
G1P1, spontaneous vaginal delivery with median episiotomy at 39 weeks of gestation.
Newborn 4,508 g (9 lb 15 oz), APGARs: 8 at 1 min, 9 at 5 min
group B streptococcus 8-hemolytic: positive (negative)
Received 2 doses of Intravenous penicillin G while in laborâ€
complete the following sentence by using the lists of options. The client is at highest risk for developing ---evidenced by the client's ---
Rationale:
Endometritis is the condition the client is at highest risk for, evidenced by the client's median episiotomy and delivery details. Endometritis is an infection of the uterine lining, commonly occurring postpartum, especially with invasive procedures like episiotomy and prolonged labor, increasing susceptibility to bacterial invasion despite antibiotic administration. This client’s delivery and episiotomy heighten infection risk.
B: Mastitis usually develops from milk stasis or nipple trauma during breastfeeding, unrelated to episiotomy or delivery complications described here, making it less relevant in this context.
C: Postpartum hemorrhage primarily involves excessive bleeding after delivery, not directly linked to the client’s episiotomy or infection risk factors noted in the history.
D: Group B streptococcus positive status is an important infection risk factor but here it was negative, and thus not a current risk for this client.
E: Spontaneous vaginal delivery describes the mode of birth, not a pathological risk; it does not inherently increase infection or complication risk.
F: Median episiotomy is a procedure, not a condition; it contributes to risk factors but is not the diagnosis or outcome itself.
Client preoperative for a neobladder urinary diversion
A nurse is teaching a client who is preoperative for a neobladder urinary diversion. Which of the following statements should the nurse make?
Rationale:
You will have an internal pouch to store your urine. This is accurate because a neobladder urinary diversion involves creating an internal reservoir from intestinal tissue to store urine, allowing for more normal urination control. The client empties the neobladder voluntarily, distinguishing it from other urinary diversions that require external collection devices or lack voluntary control over urination.
B: You will not be able to control your urination. This does not apply since a neobladder allows voluntary control, unlike some diversions where continence is not possible due to external collection or lack of sphincter function.
C: You will have a stoma that is located in your abdomen. Neobladder diversions typically do not involve a permanent stoma; urine is voided through the urethra, so this statement misrepresents the procedure’s outcome.
D: You will wear an external collection bag to drain your urine. External bags are used in ileal conduits, not neobladders, which store urine internally and allow voiding through the urethra, eliminating the need for external drainage devices.
A nurse is providing discharge teaching about car seat safety to a parent of a newborn. Which of the following statements by the parent indicates an understanding of the teaching?
Rationale:
Positioning the baby at a 45-degree angle in the car seat ensures proper head and airway alignment, reducing the risk of airway obstruction and injury during travel. This reclined angle supports newborns’ necks, which lack muscle strength, and maintains safety guidelines for infant car seats, thereby demonstrating correct understanding of car seat safety principles.
B: Placing a newborn in the front seat, even with the airbag off, increases risk due to potential injury from dashboard impact and airbags. Newborns should always be in the rear seat for maximum protection.
C: Turning the car seat forward at 15 pounds is premature; most guidelines recommend rear-facing until at least 20 pounds and age two to maximize spinal and head protection.
D: Forward-facing car seats are unsafe for newborns because their neck muscles are underdeveloped, increasing injury risk. Infants must remain rear-facing in the back seat until they meet size and age criteria.
A nurse is caring for a client in labor who is experiencing abruptio placentae.
What findings should the nurse expect?
Rationale:
Uterine tenderness is expected in a client experiencing abruptio placentae. This condition involves premature separation of the placenta, causing painful, rigid uterine contractions and tenderness due to bleeding into the uterine muscle. The tenderness signifies localized inflammation and irritation from hemorrhage, making it a hallmark clinical sign. Prompt recognition is crucial for maternal and fetal outcomes.
A: Leukorrhea pertains to vaginal discharge and is not associated with abruptio placentae symptoms or uterine changes. It does not reflect placental separation or bleeding complications.
B: Hypertension may contribute to abruptio placentae risk but is not an immediate finding during placental abruption episodes. It is a preceding condition, not a direct symptom.
D: Fetal tachycardia may occur secondary to distress but is not a primary or reliable indicator of abruptio placentae; uterine tenderness remains more specific for diagnosis.
Four clients reviewing contraception options
Which client has a contraindication for receiving oral contraceptives?
Rationale:
A 38-year-old client who reports smoking one pack of cigarettes every day has a contraindication for receiving oral contraceptives. Smoking, especially in women over 35, significantly increases the risk of serious cardiovascular events like blood clots when combined with oral contraceptives, making this option unsafe. The other clients’ conditions do not pose the same level of risk for oral contraceptive use.
B: A 28-year-old client with a history of pelvic inflammatory disease does not have a direct contraindication for oral contraceptives, as these medications do not exacerbate or cause PID recurrence.
C: A 32-year-old client with benign breast disease is not contraindicated from oral contraceptive use, since benign breast conditions typically do not increase risks associated with hormonal contraceptives.
D: A 26-year-old client with migraine headaches at the start of each menstrual cycle may require caution but does not automatically contraindicate oral contraceptive use unless aura or neurological symptoms are present.
A nurse is planning care for a client who is 1 hr postpartum and has preeclampsia without severe features.
What actions should the nurse plan to take?
Rationale:
Assess for edema.
Edema assessment is essential for a postpartum client with preeclampsia without severe features because it indicates fluid retention and worsening hypertension. Monitoring edema helps detect early signs of complications, guiding timely interventions to prevent progression to severe preeclampsia or eclampsia. Regular evaluation ensures appropriate management and supports maternal safety during the critical postpartum period.
B: Administer an IV bolus of lactated Ringer's. This action risks fluid overload in preeclampsia patients, potentially exacerbating hypertension and edema, making it unsuitable without specific indications or physician orders.
C: Obtain a prescription for misoprostol. Misoprostol is primarily used for uterine contractions or hemorrhage management, not for managing preeclampsia symptoms or edema postpartum.
D: Assist the client with food intake. While supportive care is important, assisting with food intake does not directly address monitoring or managing preeclampsia-related complications such as edema.
Child with suspected acute rheumatic fever
A nurse is obtaining a health history from a child who has suspected acute rheumatic fever. Which of the following questions should the nurse ask?
Rationale:
A: Has your son had a sore throat recently? Asking about a recent sore throat is crucial because acute rheumatic fever often follows untreated or poorly treated streptococcal pharyngitis. Identifying this symptom helps link the child’s current condition to a preceding infection, guiding appropriate diagnosis and management of rheumatic fever.
B: Has your child had any injuries recently? This question does not directly relate to acute rheumatic fever, as trauma or injuries are unrelated to the disease’s infectious and inflammatory nature.
C: Was your son born with this cardiac defect? Acute rheumatic fever develops after infection, not from congenital defects, making this question irrelevant for initial assessment.
D: Have you given your child aspirin in the past 2 weeks? While aspirin can be used in treatment, this query is secondary to identifying the initial infection triggering rheumatic fever.