A nurse is caring for a middle adult client who has just received the diagnosis of endometrial cancer. In taking a nursing history, which of the following
... [Show More] manifestations is likely to be reported by this client?
a. Unilateral swelling on the posterior of the vulva
b. Extreme abdominal pain with intercourse
c. Green, malodorous vaginal discharge
d. Postmenopausal bleeding - d. Postmenopausal bleeding
A nurse is caring for a preterm newborn who has a nasogastric tube and who recently began intermittent gavage feedings of formula. The nurse notes increased abdominal distention, lethargy, bloody stools, and increasing gastric residuals before feedings. The nurse should suspect which of the following?
a. Overstimulation
b. Necrotizing enterocolitis
c. Need for placement of a gastrostomy tube
d. Intraventricular hemorrhage - b. Necrotizing enterocolitis
A nurse is teaching a client who is postpartum and has a new prescription for an injection of Rho (D) immunoglobulin. Which of the following should be included in the teaching?
a. It prevents the formation of Rh antibodies in mothers who are Rh negative.
b. It destroys Rh antibodies in mothers who are Rh negative.
c. It destroys Rh antibodies in newborns who are Rh positive.
d. It prevents the formation of Rh antibodies in newborns who are Rh positive. - a. It prevents the formation of Rh antibodies in mothers who are Rh negative.
A nurse is caring for an adolescent client who is gravida 1 and para 0. The client was admitted to the hospital at 38 weeks of gestation with a diagnosis of preeclampsia. Which of the following findings should the nurse identify as inconsistent with preeclampsia?
a. 1+ pitting sacral edema
b. 3+ protein in the urine
c. Blood pressure 148/98 mm Hg
d. Deep tendon reflexes of +1 - d. Deep tendon reflexes of +1
A nurse in a clinic is teaching information about cervical polyps with a client who has a new diagnosis. Which of the following information should the nurse include in the teaching?
a. Avoid using tampons during menstruation.
b. Cervical polyps are a precursor to the development of cervical cancer.
c. Cervical polyps affect women before the age of 40.
d. Postcoital bleeding may occur. - d. Postcoital bleeding may occur.
A nurse is assessing a client who is 3 days postpartum and is breastfeeding. The nurse notes that the fundus is three fingerbreadths below the umbilicus, lochia rubra is moderate, and the breasts are hard and warm to palpation. Which of the following interpretations of these findings should the nurse make?
a. The client is exhibiting early indications of mastitis.
b. Additional interventions are not indicated at this time.
c. Application of a heating pad to the breasts is indicated.
d. The client should be advised to remove her nursing bra. - b. Additional interventions are not indicated at this time.
A nurse is preparing to administer magnesium sulfate IV to a client who is experiencing preterm labor. Which of the following is the priority nursing assessment for this client?
a. Temperature
b. Fetal heart rate (FHR)
c. Bowel sounds
d. Respiratory rate - d. Respiratory rate
A nurse in a clinic is caring for a client who is 3 weeks postpartum following the birth of a healthy newborn. The client reports feeling "down" and sad, having no energy, and wanting to cry. Which of the following is a priority action by the nurse?
a. Assist the family to identify prior use of positive coping skills in family crises.
b. Ask the client if she has considered harming her newborn.
c. Anticipate a prescription by the provider for an antidepressant.
d. Reinforce postpartum and newborn care discharge teaching. - b. Ask the client if she has considered harming her newborn.
A nurse in a clinic is caring for a client who is at 11 weeks of gestation and reports that she has had slight occasional vaginal bleeding over the past 2 weeks. Following an examination by the provider, the client is told that the fetus has died and that the placenta, fetus, and tissues remain in the uterus. How should the nurse document these findings?
a. Incomplete miscarriage
b. Missed miscarriage
c. Inevitable miscarriage
d. Complete miscarriage - b. Missed miscarriage
A nurse is caring for a client who reports unrelieved episiotomy pain 8 hr following a vaginal birth. Which of the following actions should the nurse take?
a. Apply an ice pack to the affected area.
b. Offer a warm sitz bath.
c. Provide a squeeze bottle of antiseptic solution.
d. Place a hot pack to the perineum. - a. Apply an ice pack to the affected area. [Show Less]