Which infant is most likely to express Rh incompatibility?
Rationale:
An infant of an Rh-negative mother and a father who is Rh positive and homozygous for the Rh factor is most likely to express Rh incompatibility. This situation guarantees the infant inherits the Rh-positive antigen, triggering the maternal immune system to produce antibodies against the Rh factor, potentially causing hemolytic disease of the newborn due to immune-mediated red blood cell destruction.
B: Infant who is Rh negative and a mother who is Rh negative cannot develop Rh incompatibility since both lack the Rh antigen, preventing maternal sensitization or antibody production against Rh-positive red cells.
C: Infant of an Rh-negative mother and a heterozygous Rh-positive father has a 50% chance of being Rh positive, lowering the likelihood of Rh incompatibility compared to a homozygous Rh-positive father.
D: Infant who is Rh positive and a mother who is Rh positive will not experience Rh incompatibility because the mother’s immune system recognizes the Rh antigen as self, avoiding antibody formation.
Which should the nurse recommend to the client to relieve premenstrual syndrome (PMS) symptoms? Select all that apply.
Rationale:
Decreasing fiber should be recommended to relieve premenstrual syndrome (PMS) symptoms. Reducing fiber intake can help alleviate bloating and gastrointestinal discomfort often associated with PMS. High fiber diets may exacerbate these symptoms by increasing gas and abdominal distension, so adjusting fiber consumption can provide symptomatic relief and improve overall comfort during the premenstrual phase.
A: NSAIDs to decrease pain provide symptom relief but primarily target pain, not the broader range of PMS symptoms like bloating or mood changes, making them less comprehensive for overall PMS management.
B: Exercise 5 to 6 times a week may improve general health but excessive exercise can increase stress hormones, potentially worsening PMS symptoms rather than consistently alleviating them.
C: Decreasing caffeine is often advised to reduce irritability and breast tenderness, but its effects vary widely and are less directly linked to relieving core PMS symptoms compared to dietary fiber adjustments.
The nurse is grading a woman's reflexes. Which of the following grades would indicate reflexes that are slightly brisker than normal?
Rationale:
Reflexes that are slightly brisker than normal are graded as +3. A +3 grade indicates reflexes that are more pronounced than the typical response, suggesting increased excitability without signs of pathology. This grading helps differentiate normal reflex activity from those that are hypoactive (+1), normal (+2), or pathologically hyperactive (+4), providing accurate neurological assessment.
A: +1 reflects diminished or hypoactive reflexes, indicating less than normal activity and not increased briskness.
B: +2 represents normal reflexes, showing no deviation towards increased or decreased response intensity.
D: +4 denotes hyperactive reflexes with clonus, which are pathologically exaggerated beyond slightly brisker reflexes.
What would the nurse include when instructing parents about positioning their toddler who has just had a body spica cast applied?
Rationale:
The nurse would instruct parents to change the child's position frequently. Frequent repositioning prevents pressure ulcers and promotes circulation, especially important for toddlers in body spica casts who have limited mobility. It also helps maintain skin integrity and comfort by reducing prolonged pressure on any one area. This practice is essential for overall healing and preventing complications in immobilized children.
A: Prop the child upright with pillows for meals can cause discomfort and pressure on the cast, potentially compromising alignment and increasing risk of skin breakdown. Upright positioning during meals is not the safest primary instruction.
B: Use the bar between the legs to turn the child risks damaging the cast or causing injury. The bar is structural, not a lever, so turning the child safely requires careful repositioning without applying force to the bar.
C: Put the child on her abdomen to sleep applies pressure on the cast and abdomen, increasing discomfort and risk of skin breakdown. Prone positioning is contraindicated due to restricted mobility and cast placement.
Mastectomy is usually recommended for which women?
Rationale:
Mastectomy is usually recommended for those who have multiple tumors in the breast in several quadrants. This approach is necessary because widespread tumor presence across different breast areas makes breast-conserving surgery less effective or feasible. Removing the entire breast reduces the risk of recurrence and ensures complete excision when tumors are dispersed, enhancing overall treatment success.
A: Those who have not had radiation to the breast radiation status alone does not dictate mastectomy necessity; treatment decisions depend more on tumor characteristics and distribution rather than prior radiation exposure.
C: Those with no extensive DCIS absence of extensive ductal carcinoma in situ usually favors breast conservation; mastectomy is typically reserved for more widespread or multifocal disease.
D: Those with a small tumor compared to breast volume small tumors relative to breast size often qualify for lumpectomy, preserving breast tissue, making mastectomy unnecessary in such cases.
A woman is noted to have multiple soft warts on her perineum and rectal areas. The nurse suspects that this client has which type of infection?
Rationale:
The woman most likely has an HPV infection. Human papillomavirus (HPV) commonly causes multiple soft warts, particularly in the perineal and rectal regions. These warts are characteristic of HPV’s cutaneous manifestations, differentiating it from other infections. The presence of soft, fleshy growths strongly indicates HPV rather than viral or bacterial causes producing different lesions or symptoms.
A: HIV primarily causes immunosuppression and opportunistic infections rather than soft warts; it does not typically present with multiple soft perineal or rectal warts, making this an unlikely diagnosis.
C: Syphilis usually manifests with painless ulcers or chancres in early stages, not multiple soft warts; its lesions have a distinct appearance and progression unlike the described warty growths.
D: Herpes simplex virus causes painful vesicles and ulcerations, not soft warts; its lesions are typically fluid-filled blisters that rupture, differing significantly from the described soft wart presentation.
The test used to screen for gestational diabetes is the:
Rationale:
The test used to screen for gestational diabetes is the Glucose challenge test. This screening method involves consuming a glucose solution followed by blood sugar measurement, effectively identifying abnormal glucose metabolism during pregnancy. It serves as a preliminary assessment before confirming diagnosis with more definitive tests, making it the standard initial approach for detecting gestational diabetes in expectant mothers.
A: Glycosylated hemoglobin test measures average blood glucose over months, not suitable for early gestational diabetes detection due to physiological changes in pregnancy affecting accuracy.
C: Oral glucose tolerance test confirms diagnosis after initial screening, not primarily used for initial gestational diabetes screening but as a follow-up procedure.
D: Postprandial glucose test measures blood sugar after meals, less standardized and not recommended as a primary screening test for gestational diabetes.
According to the standard staging classification for breast cancer, which criteria reflects stage 2 breast cancer?
Rationale:
Stage 2 breast cancer is characterized by a tumor larger than 2 to 5 cm with no regional lymph node involvement and no distant metastasis. This classification fits the tumor size and absence of lymph node or distant spread criteria defining stage 2. It distinguishes from smaller tumors without nodal spread and larger tumors with nodal fixation or metastasis, aligning precisely with stage 2 definitions.
A: Tumor smaller than 2 cm, no regional lymph node metastasis, no distant metastasis corresponds to stage 1, reflecting early disease without nodal involvement or significant tumor growth.
B: No evidence of tumor; metastasis to lymph nodes fixed to one another or to other structure but no distant metastasis indicates advanced nodal disease, characteristic of stage 3, not stage 2.
C: Tumor larger than 5 cm; metastasis to lymph nodes fixed to one another or to other structure; no distant metastasis represents stage 3 breast cancer due to size and nodal fixation.
The nurse is caring for an Rh-negative mother on the postpartum unit. What scenario indicates the need to administer RhoGAM to this patient?
Rationale:
RhoGAM should be administered when an Rh-negative mother has had an Rh-positive infant and is pregnant with an Rh-positive fetus.
This situation poses a risk of Rh sensitization, where the mother’s immune system may produce antibodies against Rh-positive fetal red blood cells, potentially causing hemolytic disease in current or future pregnancies. RhoGAM prevents this immune response by neutralizing fetal Rh-positive cells in maternal circulation.
A: She has had one Rh-negative child and is pregnant with an Rh-negative child. No Rh incompatibility risk exists since both children are Rh-negative, eliminating the need for RhoGAM.
C: She has had an O-negative child and is pregnant with a B-negative child. Both children are Rh-negative, so no Rh antibody formation or RhoGAM administration is warranted.
D: She is a primipara with an O-negative child. Being a first-time mother with an Rh-negative infant does not trigger Rh sensitization; therefore, RhoGAM is unnecessary in this case.
Which factors contribute to a woman's perception of her body? Select all that apply.
Rationale:
A woman's perception of her body is influenced by sexuality. Sexuality directly shapes how women view their physical selves, impacting confidence, self-esteem, and body image through personal identity and intimate relationships. This factor is deeply intertwined with emotions and societal expectations, making it a primary contributor to how women perceive and relate to their own bodies on a psychological and social level.
A: Role of motherhood Motherhood affects many life aspects but does not directly determine body perception; it influences identity and lifestyle rather than immediate self-image tied to body evaluation or intimate self-awareness.
C: Relationships at work Workplace interactions generally impact professional identity and stress levels but lack a direct, profound influence on women's body image or personal physical self-assessment compared to intimate or social relationships.
D: Family and social relationships Although these relationships shape emotional support and social identity, they do not uniquely or primarily dictate a woman’s individual perception of her body as sexuality distinctly does.
The client receives zidovudine (Retrovir) for treatment of HIV infection. Which assessment data indicates an adverse reaction to the drug?
Rationale:
Decreased WBC count indicates an adverse reaction to zidovudine. Zidovudine can cause bone marrow suppression, leading to leukopenia, which manifests as a reduced white blood cell count. Monitoring WBC levels is essential to detect this hematologic toxicity early, preventing complications like infections. This side effect directly reflects the drug's impact on blood cell production, confirming its adverse nature.
A: Cough does not directly relate to zidovudine's common adverse effects, which predominantly involve hematologic changes rather than respiratory symptoms.
B: Enlarged lymph nodes typically indicate infection or immune response, not a direct adverse reaction to zidovudine therapy.
D: Fever may suggest infection but is not a specific adverse effect of zidovudine itself, unlike hematologic toxicity such as decreased WBC count.
A nurse is providing preoperative teaching for a woman who is undergoing a total mastectomy. Which will this teaching include? Select all that apply.
Rationale:
Elevating the affected arm with pillows is included in preoperative teaching to reduce swelling and promote lymphatic drainage after a total mastectomy. This positioning helps minimize discomfort and prevents complications such as lymphedema by encouraging proper circulation and reducing fluid accumulation in the arm, which is critical for postoperative recovery and maintaining arm function.
A: Explain that she will have an IV, a drain, and a dressing in place on awakening. Tell her about expectations she may have regarding physical appearance, pain management, equipment that will be used (IVs, drains, etc.). This describes general postoperative information but omits specific arm care necessary post-mastectomy, making it incomplete for preoperative teaching focused on arm elevation.
B: Explain that she will be provided pain management as needed; monitor and review the pain scale to be used to identify level of intensity. Pain management is important but is a standard practice rather than a specific preoperative teaching focus related to arm positioning or postoperative arm care.
D: Turn the woman every 4 hours, alternating between the unaffected side and affected side. To prevent pneumonia and complications, have her cough and take deep breaths every 2 hours, while nurse applies support to the chest. This is general postoperative respiratory care, not specific to preoperative instruction or arm elevation following mastectomy.
A 29-week-gestation woman diagnosed with severe preeclampsia is noted to have blood pressure of 170/112, 4+ proteinuria, and a weight gain of 10 pounds over the past 2 days. Which of the following signs/symptoms would the nurse also expect to see?
Rationale:
Papilledema is expected in severe preeclampsia due to increased intracranial pressure from hypertension. This symptom indicates central nervous system involvement, reflecting the severity of the condition. The patient’s elevated blood pressure and proteinuria support the likelihood of neurological complications, making papilledema a key clinical sign nurses should monitor closely in such cases to assess for progression and complications.
A: Fundal height of 32 cm. Fundal height typically correlates with gestational age. At 29 weeks, 32 cm would be slightly larger but not specifically indicative of severe preeclampsia or its neurological symptoms. This measurement does not directly correlate with the critical signs expected here.
C: Patellar reflexes of +2. A +2 patellar reflex is considered normal. Severe preeclampsia often involves hyperreflexia or exaggerated reflexes, so normal reflexes do not align with the expected neurological findings in this condition.
D: Nystagmus. Nystagmus refers to involuntary eye movements primarily related to vestibular or neurological disorders unrelated to preeclampsia. It is not a typical symptom associated with hypertensive complications in pregnancy and thus unlikely in this context.
What is the highest priority nursing intervention for an infant born with myelomeningocele?
Rationale:
Protect the sac from injury.
Protecting the sac is critical because it prevents infection and further neurological damage. The sac contains exposed neural tissue and cerebrospinal fluid, so maintaining its integrity is essential to reduce complications. Immediate protection reduces the risk of meningitis and preserves neurological function before surgical closure, which is typically done soon after birth, not delayed.
B: Prepare the parents for the child's paralysis from the waist down addresses long-term outcomes but does not prioritize immediate protection of the vulnerable sac, which is essential to prevent infection and preserve function.
C: Prepare the parents for closure of the sac when the child is approximately 2 years of age is inaccurate since surgical closure usually occurs shortly after birth to minimize infection risks and complications.
D: Assess for cyanosis is unrelated to the primary concern with myelomeningocele, which involves protecting the neural sac rather than monitoring respiratory or circulatory status initially.
A 60-year-old client with a palpable mass to the right adnexa and family history of ovarian cancer is seen by the HCP. The nurse anticipates the order for which of the following laboratory results?
Rationale:
CA-125 is the anticipated laboratory test because it is a tumor marker commonly elevated in ovarian cancer and helps in assessing adnexal masses, especially with a family history of ovarian malignancy. This marker aids in diagnosis, monitoring treatment response, and detecting recurrence, making it essential for evaluating suspected ovarian tumors in this patient.
A: CBC evaluates general health and detects anemia or infection but does not specifically indicate ovarian cancer or adnexal masses, making it less relevant in this context.
B: Blood glucose measures blood sugar levels, unrelated to ovarian cancer diagnosis or adnexal mass evaluation, so it is not the priority test here.
D: FSH and LH assess ovarian function and hormonal status, which are not primary concerns when investigating a palpable adnexal mass with cancer history.
Intrapartum nursing care for a woman who has sickle cell disease focuses on:
Rationale:
Maintaining oxygenation and preventing dehydration is the primary focus of intrapartum nursing care for a woman with sickle cell disease. Ensuring adequate oxygen levels prevents sickling crises by reducing hypoxia, while hydration keeps blood viscosity low, minimizing vaso-occlusive episodes. These interventions directly address the pathophysiology of sickle cell disease during labor, promoting maternal and fetal well-being.
B: Controlling pain and avoiding unnecessary movement helps comfort but does not directly prevent sickling crises as effectively as maintaining oxygenation and hydration during labor.
C: Preventing excess exertion and limiting visitors may reduce stress but lacks direct impact on oxygenation or hydration critical for sickle cell management intrapartum.
D: Increasing calorie intake and avoiding internal monitoring do not target hypoxia or dehydration, which are crucial factors in managing sickle cell disease during labor.
The nurse is caring for an infant with hydrocephalus. What nursing action is most important for this nurse to implement?
Rationale:
Supporting the head is most important when caring for an infant with hydrocephalus. Proper head support prevents injury due to the increased size and fragility of the infant’s head caused by excessive cerebrospinal fluid. This action minimizes risk of trauma, promotes comfort, and aids in maintaining proper alignment, crucial for neurological safety and overall well-being in these vulnerable patients.
A: Align the limbs Maintaining limb alignment is beneficial for general care but does not address the primary concern of head support in hydrocephalus, where cranial protection is paramount to prevent injury and discomfort.
C: Keep the head lower than the hip Positioning the head lower than the hips can increase intracranial pressure, which is hazardous in hydrocephalus management and contradicts proper care protocols focused on pressure reduction.
D: Check intake and output Monitoring intake and output is important for fluid balance but does not directly impact the critical need to protect and support the enlarged, fragile head in infants with hydrocephalus.
Which is a constellation of physical and psychological symptoms beginning in the luteal phase of the menstrual cycle and followed by a symptom-free period?
Rationale:
Premenstrual syndrome is a constellation of physical and psychological symptoms beginning in the luteal phase of the menstrual cycle and followed by a symptom-free period. This condition specifically manifests cyclically before menstruation, distinguishing it from other disorders by its timing and symptom pattern linked to hormonal fluctuations during the luteal phase, resolving after menstruation starts.
A: Endometriosis involves ectopic endometrial tissue causing chronic pelvic pain and infertility, not a cyclic symptom pattern limited to the luteal phase. It is characterized by persistent pain rather than periodic symptom-free intervals.
B: Abnormal uterine bleeding refers to irregular menstrual bleeding patterns, lacking the psychological and physical symptom constellation or the clear luteal phase onset described in the question.
D: Depression is a mood disorder with persistent symptoms that do not follow menstrual cycle phases or demonstrate a symptom-free interval, contrasting with the cyclical nature of premenstrual syndrome.
Reduction in congenital rubella is best accomplished by:
Rationale:
Reduction in congenital rubella is best accomplished by immunizing susceptible women at least 28 days before they become pregnant. Vaccination prior to pregnancy ensures immunity, preventing maternal infection and subsequent fetal transmission. This proactive approach effectively reduces birth defects associated with rubella, making it the primary preventive strategy endorsed by health authorities for protecting both mother and child from congenital rubella syndrome.
A: Avoiding contact with young children when infections are prevalent minimizes exposure risk but does not guarantee immunity or prevent maternal infection, making it a less reliable method for congenital rubella reduction.
B: Taking prophylactic antibiotics during pregnancy does not influence viral infections like rubella, as antibiotics target bacteria, not viruses, rendering this approach ineffective for congenital rubella prevention.
C: Testing the rubella titer at the first prenatal visit identifies immunity status but does not reduce congenital rubella unless followed by vaccination before pregnancy, making it a diagnostic rather than preventive measure.
Choose the appropriate infant care teaching for a woman who has given birth by cesarean because of active genital herpes.
Rationale:
Thoroughly wash your hands before handling the infant. Proper hand hygiene is essential to prevent transmitting herpes simplex virus to the newborn, especially since active genital herpes poses a high risk of neonatal infection. Washing hands reduces viral spread significantly, protecting the infant during care and feeding. This precaution is critical in the postpartum period following cesarean delivery with active lesions.
A: Do not breastfeed the infant until all lesions are healed assumes breastfeeding transmits herpes, but the virus rarely passes through breast milk; the main transmission route is direct contact, not breastfeeding itself.
C: Wear a mask when breastfeeding or holding the infant close suggests respiratory transmission risk, which is less relevant since herpes spreads mainly through direct skin-to-skin contact with lesions.
D: No special precautions are needed when caring for the infant ignores the high risk of neonatal herpes infection from contact with active lesions, making careful hygiene and precautions vital to infant safety.
A 40-year-old woman has just been diagnosed with stage 2 breast cancer. Which of the following are common reactions? Select all that apply.
Rationale:
Anxiety regarding changes in family reactions, body image, disability, and pain is a common reaction for patients diagnosed with stage 2 breast cancer. This anxiety stems from anticipated alterations in personal relationships, self-perception, physical capabilities, and potential suffering, which are typical concerns affecting emotional wellbeing during cancer diagnosis and treatment phases, influencing coping mechanisms and psychological adjustment.
B: Concern about disruptions related to treatment focuses on logistical or routine interruptions rather than the deeper emotional and physical anxieties directly connected to cancer’s impact on identity and relationships.
C: Fear of death, while possible, is less universally immediate compared to anxiety about tangible changes in family dynamics, body image, and pain that directly confront patients in early-stage breast cancer.
D: Decisional conflict related to controversies about treatment options pertains more to complex medical choices rather than the initial emotional response centered on personal and familial implications of the diagnosis.
Choose the appropriate infant care teaching for a woman who has given birth by cesarean because of active genital herpes.
Rationale:
Thoroughly wash your hands before handling the infant. Hand hygiene is crucial to prevent transmission of herpes simplex virus from mother to infant, especially since direct contact with active lesions can cause neonatal herpes, which is severe and potentially life-threatening. Washing hands minimizes the risk of virus spread during infant care, ensuring safer interaction despite the mother’s active genital herpes condition.
A: Do not breastfeed the infant until all lesions are healed assumes virus spreads through breast milk, but herpes simplex virus primarily transmits via direct contact, not breastfeeding, making this precaution unnecessary.
C: Wear a mask when breastfeeding or holding the infant close misattributes transmission to respiratory droplets, whereas herpes simplex virus spreads mainly through skin contact with lesions, so masks offer limited protection.
D: No special precautions are needed when caring for the infant disregards the high risk of neonatal herpes from direct contact with lesions, neglecting essential hygiene measures that protect the newborn’s health.
For HIV treatment, the pregnant woman should be expected to receive:
Rationale:
Zidovudine is the preferred medication for treating HIV in pregnant women to reduce the risk of mother-to-child transmission. It is a nucleoside reverse transcriptase inhibitor (NRTI) proven effective and safe during pregnancy, significantly lowering viral load and preventing neonatal HIV infection. This antiretroviral drug is widely recommended by health authorities for managing HIV in expectant mothers.
A: Antibiotics target bacterial infections and do not affect viral replication, making them unsuitable for HIV treatment in pregnancy.
B: Protease analogues is a misnomer; the correct term is protease inhibitors, which are used, but Zidovudine is the primary drug specifically recommended during pregnancy.
D: Acyclovir treats herpes viruses and lacks efficacy against HIV, thus it is not applicable for HIV treatment in pregnant women.
The primary fetal risk when the mother has any type of anemia is for:
Rationale:
Reduced oxygen delivery is the primary fetal risk when the mother has any type of anemia. Anemia decreases the number of red blood cells and hemoglobin, reducing the oxygen transport capacity in maternal blood. This insufficiency can impair fetal oxygenation, potentially leading to hypoxia, growth restriction, or even fetal distress, emphasizing the critical importance of adequate oxygen delivery during pregnancy.
A: Neonatal anemia focuses on the newborn’s red blood cell count, which is not the immediate fetal risk caused by maternal anemia. The primary concern centers on oxygen supply, not direct neonatal blood levels.
B: Elevated bilirubin level relates to jaundice due to red blood cell breakdown, but maternal anemia primarily affects oxygen transport, not bilirubin metabolism or accumulation in the fetus.
C: Limited infection defenses address immune function, whereas anemia chiefly compromises oxygen delivery. Immune system impairment is not the foremost fetal complication arising from maternal anemia.
An absence of what may facilitate the occurrence of bacterial vaginosis?
Rationale:
An absence of Lactobacillus acidophilus may facilitate the occurrence of bacterial vaginosis. Lactobacillus acidophilus maintains vaginal pH by producing lactic acid, inhibiting pathogenic bacterial growth. Its depletion disrupts the natural microbial balance, allowing overgrowth of anaerobic bacteria like Gardnerella vaginalis, leading to bacterial vaginosis. Thus, its absence directly contributes to the condition's development by weakening protective mechanisms.
A: Antibodies Lack of antibodies alone does not directly cause bacterial vaginosis; the condition primarily relates to microbial imbalance rather than immune deficiency. Antibodies play a lesser role in maintaining vaginal flora equilibrium.
C: Gardnerella vaginalis Presence of Gardnerella vaginalis is associated with bacterial vaginosis, not its absence; it contributes to the infection rather than prevents it.
D: Vaginal mucosa Intact vaginal mucosa is essential for protection; its absence would cause more severe damage, but bacterial vaginosis is mainly linked to microbial rather than tissue factors.
The client calls the nurse and states she has not had a menstrual cycle in 3 months. What does the nurse know is the most common cause of secondary amenorrhea?
Rationale:
Pregnancy is the most common cause of secondary amenorrhea. This condition, defined as the absence of menstruation for three months or more in a woman who previously had regular cycles, is most frequently due to pregnancy rather than pathological or hormonal causes. Nurses must first rule out pregnancy before considering other less common etiologies for missed periods.
A: Weight loss contributes to menstrual irregularities but is a less common cause of secondary amenorrhea compared to pregnancy. It typically affects menstrual cycles through hormonal disruption rather than being the primary cause.
C: Cancer is a rare cause of secondary amenorrhea and usually presents with additional symptoms beyond menstrual absence, making it an unlikely first consideration in this scenario.
D: Menopause generally occurs in women over 45 and is unlikely in younger women experiencing three months of missed cycles, rendering it an improbable cause of secondary amenorrhea here.
A public health nurse is teaching a group about STIs at a local community center. Which statement made by the group demonstrates a good understanding of the disease process?
Rationale:
Sexual partners of the infected person must also be treated. This statement reflects a clear understanding that treating only the infected individual is insufficient to prevent reinfection and halt transmission. Public health measures emphasize partner notification and treatment to control STI spread effectively. Addressing all sexual contacts breaks the chain of infection and reduces community prevalence of these diseases.
A: The infection can only be spread when a person is symptomatic. This is inaccurate because many STIs can be transmitted during asymptomatic phases, making silent spread possible without visible symptoms.
B: I can only get the disease through vaginal intercourse. This is misleading since STIs can be transmitted through oral, anal, and other sexual activities, not just vaginal intercourse.
D: Oral contraceptives are effective in protecting against STIs. Oral contraceptives prevent pregnancy but do not offer any barrier to infection, so they do not provide protection against sexually transmitted infections.
The pregnant woman who becomes infected with chickenpox should be taught to report promptly:
Rationale:
The pregnant woman who becomes infected with chickenpox should be taught to report promptly cough or dyspnea. This is crucial because respiratory symptoms like cough or difficulty breathing may indicate varicella pneumonia, a severe complication in pregnancy requiring immediate medical attention to prevent maternal and fetal morbidity. Early recognition allows timely intervention and better outcomes.
B: Severe skin itching primarily reflects a common symptom of chickenpox but does not signal an urgent complication requiring immediate reporting. Monitoring itching alone is insufficient for identifying life-threatening issues.
C: Joint pain is not a typical emergent symptom of chickenpox in pregnancy and does not represent an immediate threat necessitating urgent medical evaluation or intervention.
D: Increased urination is unrelated to chickenpox infection and does not indicate any urgent chickenpox-associated complications in pregnancy, thus not warranting prompt notification.
The nurse is providing a 20-year-old woman diagnosed with fibrocystic disease with education about her condition. Which information should be included? Select all that apply.
Rationale:
Pain or tenderness is never present with fibrocystic disease. This statement is accurate as fibrocystic breast changes typically cause discomfort, but pain or tenderness is not always a symptom. Fibrocystic disease involves benign cyst formation and fibrous tissue proliferation, often influenced by hormonal fluctuations, but pain is variable and not a defining feature in all cases.
B: The cysts are thought to be hormone related. Hormonal influence is significant in fibrocystic disease, but this option does not address the pain or tenderness aspect, which is the crucial educational point for the patient.
C: The cysts can be of any size, can feel like small lumps or grapes, and can be soft or firm. While descriptive, this option focuses on physical characteristics without clarifying the typical symptomatology regarding pain, which is essential for patient understanding.
D: It is not a common finding in women between the ages of 30 and 50. Fibrocystic disease commonly affects women in the 30-50 age range, so this statement contradicts epidemiological data and is misleading.
A woman has been diagnosed with galactorrhea. Which signs and symptoms should the nurse expect to see? Select all that apply.
Rationale:
Galactorrhea is characterized by less interest in sex. This symptom arises because elevated prolactin levels associated with galactorrhea can disrupt normal hormonal balance, leading to decreased libido. The nurse should anticipate diminished sexual desire as a common manifestation, reflecting the underlying endocrine disturbance affecting reproductive and sexual functions.
A: Milky white discharge from one or both nipples Commonly linked to galactorrhea, but the question asks for signs and symptoms; this discharge, while typical, is not the sole manifestation to expect.
B: Absence of menstrual periods Amenorrhea may occur with galactorrhea but is not a universal symptom; thus, it should not be considered a definitive sign in this context.
C: Temperature intolerance Temperature intolerance is unrelated to galactorrhea’s hormonal effects and does not represent a symptom associated with this condition.