NUR 211 Growth and development/ Cellular reg/F&E PrepU

A client is diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). The nurse should anticipate which laboratory test result? A) Serum sodium level of 124 mEq/L B)Serum creatinine level of 0.4 mg/dl C)Hematocrit of 52% D)Serum blood urea nitrogen (BUN) level of 8.6 mg/dl

A Rationale: In SIADH, the posterior pituitary gland produces excess antidiuretic hormone (vasopressin), which decreases water excretion by the kidneys. This, in turn, reduces the serum sodium level, causing hyponatremia, as indicated by a serum sodium level of 124 mEq/L. In SIADH, the serum creatinine level isn't affected by the client's fluid status and remains within normal limits. A hematocrit of 52% and a BUN level of 8.6 mg/dl are elevated. Typically, the hematocrit and BUN level decrease.

A woman who delivered her infant by cesarean section 1 week ago called her physician's office to report chills, fever of 101.6℉ (38.7℃) and a poor appetite. She also tells the nurse that she is having strong afterbirth pains and her lochia has increased in volume and has an odor. Labwork shows an elevated WBC count. Which of these reported findings is the most significant finding related to the suspected diagnosis of endometritis? A)Fever B) Lochia odor C) Strong afterpains D) Elevated WBC count

A Rationale: Increased temperature is the most significant finding in this time period to support the suspicion of endometritis. The other findings are usually seen in this illness but the fever is the most significant finding. An elevated WBC count can be seen in a normal postpartal woman with values of up to 20,000 to 30, 000/ mm3.

The nurse would prepare a client for amnioinfusion when which action occurs? A) Severe variable decelerations occur and are due to cord compression. B)Fetal presenting part fails to rotate fully and descend in the pelvis. C)The fetus shows abnormal fetal heart rate patterns. D) Maternal pushing is compromised due to anesthesia.

A Rationale: Indications for amnioinfusion include severe variable decelerations resulting from cord compression, oligohydramnios (decreased amniotic fluid), postmaturity, preterm labor with rupture of the membranes, and thick meconium fluid. Failure of the fetal presenting part to rotate fully, descend in the pelvis, abnormal fetal heart rate patterns or acute pulmonary edema, and compromised maternal pushing sensations from anesthesia are indications for forceps-assisted birth, and not for amniofusion.

A 41-year-old pregnant woman and her husband are anxiously awaiting the results of various blood tests to evaluate the fetus for potential Down syndrome, neural tube defects, and spina bifida. Client education should include which information? A) Further testing will be required to confirm any diagnosis. B) The blood tests are definitive. C)Treatment can be started once the test results are back. D) A second set of screening tests can be obtained to confirm results.

A Rationale: Nursing management related to marker screening tests consists primarily of providing education about the tests. Remind the couple that a definitive diagnosis is not made without further tests such as an amniocentesis. The blood tests are not definitive but only strongly suggest the possibility of a defect. For some conditions there are no treatments. The couple may request a second set, but the health care provider will probably suggest proceeding with the more definitive methods to confirm the diagnosis.

A nurse is assessing a client after a thyroidectomy. The assessment reveals muscle twitching and tingling, along with numbness in the fingers, toes, and mouth area. The nurse should suspect which complication? A)Tetany B) Hemorrhage C)Thyroid storm D)Laryngeal nerve damage

A Rationale: Tetany may result if the parathyroid glands are excised or damaged during thyroid surgery. Hemorrhage is a potential complication after thyroid surgery but is characterized by tachycardia, hypotension, frequent swallowing, feelings of fullness at the incision site, choking, and bleeding. Thyroid storm is another term for severe hyperthyroidism — not a complication of thyroidectomy. Laryngeal nerve damage may occur postoperatively, but its signs include a hoarse voice and, possibly, acute airway obstruction.

The nurse is caring for a client who has developed SIADH. What intervention is most appropriate? A) Fluid restriction B)Transfusion of platelets C)Transfusion of fresh frozen plasma (FFP) D)Electrolyte restriction

A Rationale: The nurse also assesses for complications of increased ICP, including diabetes insipidus, and SIADH. SIADH requires fluid restriction and monitoring of serum electrolyte levels. Transfusions are unnecessary.

When caring for a patient with increased ICP the nurse knows the importance of monitoring for possible secondary complications, including syndrome of inappropriate antidiuretic hormone (SIADH). What nursing interventions would the nurse most likely initiate if the patient developed SIADH? a) Fluid restriction B)Transfusion of platelets C)Transfusion of fresh frozen plasma (FFP) D)Electrolyte restriction

A Rationale: The nurse also assesses for complications of increased ICP, including diabetes insipidus, and SIADH. SIADH requires fluid restriction and monitoring of serum electrolyte levels. Transfusions are unnecessary.

A health care provider has recommended that a client undergo thyroid diagnostic testing. During the course of therapy, the client experiences myxedema due to the administration of an inadequate dose. Which symptom should the nurse monitor for in the client? A) Cold intolerance B) High fever C) Extreme tachycardia D) Altered mental status

A Rationale: The nurse should monitor for cold intolerance, lethargy, apathy, memory impairment, emotional changes, slow speech, deep coarse voice, thick dry skin, slow pulse, constipation, weight gain, and absence of menses in a client experiencing myxedema. High fever, extreme tachycardia, and altered mental status are not the symptoms of myxedema. High fever, extreme tachycardia, and altered mental status are the symptoms of thyrotoxicosis or thyroid storm.

A client sustained a head injury when falling off of a ladder. While in the hospital, the client begins voiding large amounts of clear urine and states he is very thirsty. The client states that he feels weak, and he has had an 8-lb weight loss since admission. What should the client be tested for? A) Diabetes insipidus (DI) B)Syndrome of inappropriate antidiuretic hormone secretion (SIADH) C)Pituitary tumor D)Hypothyroidism

A Rationale: Urine output may be as high as 20 L/24 hours. Urine is dilute, with a specific gravity of 1.002 or less. Limiting fluid intake does not control urine exertion. Thirst is excessive and constant. Activities are limited by the frequent need to drink and void. Weakness, dehydration, and weight loss develop. SIADH will have the opposite clinical manifestations. The client's symptoms are related to the trauma and not a pituitary tumor. The thyroid gland does not exhibit these symptoms.

The nurse is caring for a client suspected to have a uterine rupture. The nurse predicts the fetal monitor will exhibit which pattern if this is true? A)Late decelerations B) Early decelerations C)Variable decelerations D) Mild decelerations

A Rationale: When the fetus is being deprived of oxygen the fetus will demonstrate late decelerations on the fetal monitoring strip. This is an indication the mother is in need of further assessment. Early decelerations are a normal finding. Variable decelerations usually coincide with cord compression.

At 31 weeks' gestation, a 37-year-old woman with a history of preterm birth reports cramps, vaginal pain, and low, dull backache accompanied by vaginal discharge and bleeding. Assessment reveals cervix 2.1 cm long; fetal fibronectin in cervical secretions, and cervix dilated 3 to 4 cm. Which interactions should the nurse prepare to assist with? A)Bed rest and hydration at home B) Hospitalization, tocolytic, and corticosteroids C) An emergency cesarean birth D) Careful monitoring of fetal kick counts

B Rationale: At 31 weeks' gestation, the goal would be to maintain the pregnancy as long as possible if the mother and fetus are tolerating continuation of the pregnancy. Stopping the contractions and placing the client in the hospital allow for monitoring in a safe place if the woman continues and gives birth. Administration of corticosteroids may help to develop the lungs and prepare for early preterm birth. Sending the woman home is contraindicated in the scenario described. An emergency cesarean birth is not indicated at this time. Monitoring fetal kick counts is typically done with a post-term pregnancy.

A client with a traumatic brain injury has developed increased intracranial pressure resulting in diabetes insipidus. The expected treatment would consist of which of the following? A) Fluid restriction B)Vasopressin therapy C)Hypertonic saline solution D)Diet containing extra sodium

B Rationale: Diabetes insipidus is the result of decreased secretion of antidiuretic hormone (ADH). The client has excessive urine output, decreased urine osmolality, and serum hperosmolarity. Treatment consists of administration of fluids, electrolyte replacement, and vasopressin therapy. SIADH is the result of increased secretion of antidiuretic hormone (ADH). The client becomes volume overloaded, urine output diminishes, and serum sodium concentration becomes dilute. Treatment consists of fluid restriction (less than 800 mL/day with no free water). In severe cases, careful administration of a 3% hypertonic saline solution may be therapeutic.

A client is diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH) and has been prescribed a medication to affect the posterior pituitary gland's production of antidiuretic hormone (ADH). Which nursing assessment is critical to this client's safety? A) Knowledge of the condition B)Fluid balance C)Appetite D)Constipation

B Rationale: Fluid balance needs to be monitored when patients are taking drugs that affect antidiuretic hormone (ADH). SIADH presents with fluid retention, dilution of the blood and all of the blood elements, serious issues with water balance and fluid volume. This disorder is now treated with drugs that block the ADH or vasopressin receptors, so water is no longer retained and urine is produced, helping to restore water balance. Keeping the fluid balance in check can be very tricky and patients receiving these drugs need to be closely monitored in the hospital. While the other options are appropriate, they do not have the priority when monitoring a client prescribed medications affecting ADH

A mother tells the nurse that her preschool-aged daughter with spina bifida sneezes and gets a rash when playing with brightly colored balloons, and that recently she had an allergic reaction after eating kiwi fruit and bananas. Based on the mother's report, the nurse suspects that the child may have an allergy to: A) Bananas. B)Latex C)Kiwi D)Colour dyes

B Rationale: If a child is sensitive to bananas, kiwi fruit, and chestnuts, she's likely to be allergic to latex. Children with spina bifida commonly develop an allergy to latex and shouldn't be exposed to it. Some children are allergic to dyes in foods and other products, but dyes aren't a factor in a latex allergy.

A client gave birth to a neonate with spina bifida. The client was informed during her pregnancy that this situation could occur. The nurse giving a report on the client states that the client's decision to continue with the pregnancy was selfish and that the neonate will suffer. How should the nurse proceed in caring for this client and her neonate? A)Ask the client why she didn't have an abortion. B)Accept the client's decision and care for her as she would care for any other client. C)Ask for another assignment because she doesn't agree with the client's decision to continue the pregnancy. D) Avoid going into the client's room unnecessarily.

B Rationale: It's the nurse's responsibility to care for and support the client and neonate no matter what her personal beliefs are. She shouldn't judge the client or avoid responsibility. (Don't be mean!)

A nurse has a four-patient assignment in the medical step-down unit. When planning care for the clients, which client would have the following treatment goals: fluid replacement, vasopressin replacement, and correction of underlying intracranial pathology? A) The client with diabetes mellitus. B)The client with diabetes insipidus. C)The client with diabetic ketoacidosis. D)The client with syndrome of inappropriate antidiuretic hormone (SIADH) secretion.

B Rationale: Maintaining adequate fluid, replacing vasopressin, and correcting underlying intracranial problems (typically lesions, tumors, or trauma affecting the hypothalamus or pituitary gland) are the main objectives in treating diabetes insipidus. Diabetes mellitus does not involve vasopressin deficiencies or an intracranial disorder, but rather a disturbance in the production or use of insulin. Diabetic ketoacidosis results from severe insulin insufficiency. An excess of vasopressin leads to SIADH, causing the client to retain fluid.

The nurse is caring for a client who has given birth to twins. During which time period would the nurse instruct on the possibility of a late postpartum hemorrhage? A) 24 to 48 hours after birth B) 24 hours to 12 weeks after birth C)6 weeks to 3 months after birth D) 6 weeks to 6 months after birth

B Rationale: Mothers who give birth to twins are instructed on postpartum hemorrhage at the same time as a mother with a single newborn. Delayed or late postpartum hemorrhages occur more than 24 hours but less than 12 weeks postpartum. Immediate, early, or primary postpartum hemorrhages occur within 24 hours of birth.

A woman is 5 days post-delivery and is experiencing an increase in her lochia accompanied by pelvic pain and heaviness. What lab test would the nurse anticipate to be elevated in this client? A) Iron levels B) Serum human chorionic gonadotropin (hCG) C) Hemoglobin (Hgb) D) Hematocrit (Hct)

B Rationale: The reason for a late postpartum hemorrhage is often retained placental fragments; if there are retained placental fragments, the serum hCG levels will remain high. The hematocrit and hemoglobin will both be lower, not higher, and the iron levels do not play into a late postpartum hemorrhage

In a child with diabetes insipidus, which characteristic would most likely be present in the child's health history? A)Delayed closure of the fontanels, coarse hair, and hypoglycemia in the morning B)Gradual onset of personality changes, lethargy, and blurred vision C)Vomiting early in the morning, headache, and decreased thirst D)Abrupt onset of polyuria, nocturia, and polydipsia

D Rationale Diabetes insipidus is characterized by deficient secretion of antidiuretic hormone leading to diuresis. Most children with this disorder experience an abrupt onset of symptoms, including polyuria, nocturia, and polydipsia. The other choices reflect symptoms of pituitary hyperfunction.

A client has sustained a traumatic brain injury with involvement of the hypothalamus. The health care team is concerned about the complication of diabetes insipidus. Which of the following would be an appropriate nursing intervention to monitor for early signs of diabetes insipidus? A) Assess frequent vital signs. B)Reposition frequently. C)Assess for pupillary response frequently. D)Record intake and output.

D Rationale: A record of intake and output is maintained for the client with a traumatic brain injury, especially if the client has hypothalamic involvement and is at risk for the development of diabetes insipidus. Excessive output will alert the nurse to possible fluid imbalance early in the process.

The nurse is caring for a client who has a diagnosis of syndrome of inappropriate antidiuretic hormone secretion (SIADH). The plan of care includes assessment of specific gravity every 4 hours. The results of this test will allow the nurse to assess what aspect of the client's health? A) Nutritional status B)Potassium balance C)Calcium balance D)Fluid volume status

D Rationale: A specific gravity will detect if the client has a fluid volume deficit or fluid volume excess. Nutrition, potassium, and calcium levels are not directly indicated.

A patient has been taking prednisone for several weeks after experiencing a hypersensitivity reaction. To prevent adrenal insufficiency, the nurse should ensure that the patient knows to do which of the following? A) Take the drug concurrent with levothyroxine (Synthroid). B) Take each dose of prednisone with a dose of calcium chloride. C) Gradually replace the prednisone with an OTC alternative. D) Slowly taper down the dose of prednisone, as ordered.

D Rationale: Corticosteroid dosages are reduced gradually (tapered) to allow normal adrenal function to return and to prevent steroid-induced adrenal insufficiency. There are no OTC substitutes for prednisone and neither calcium chloride nor levothyroxine addresses the risk of adrenal insufficiency.

A child is admitted to the pediatric medical unit with the diagnosis of syndrome of inappropriate antidiuretic hormone (SIADH). Based on the typical signs and symptoms of this disorder, which nursing diagnosis will the nurse identify as relating to this client? A) Delayed growth and development B)Imbalanced nutrition: More than body requirements C)Non Compliance D)Excess fluid volume

D Rationale: Syndrome of inappropriate antidiuretic hormone (SIADH) occurs when ADH (vasopressin) is secreted in the presence of low serum osmolality because the feedback mechanism that regulates ADH does not function properly. ADH continues to be released, and this leads to water retention, decreased serum sodium due to hemodilution, and extracellular fluid volume expansion; thus, Excess fluid volume from edema is the highest priority.

A nurse is assigned to care for a client experiencing early postpartum hemorrhage. The nurse is required to administer the prescribed methylergonovine maleate intramuscularly to the client. Which condition would the nurse identify as necessitating the cautious administration of this drug? A)mild fever B) respiratory problems C) low blood pressure D)cardiovascular disease

D Rationale: The nurse should know that the client with cardiovascular disease must understand that the drug has to be administered cautiously. Nurses must administer methylergonovine maleate with caution in women who have elevated blood pressure or cardiovascular disease because it causes a sudden increase in blood pressure and could initiate a cerebrovascular accident in women at risk with pre existing conditions. Low blood pressure, respiratory problems, or mild fever is not known to enforce cautious use of methylergonovine maleate in clients with early postpartum hemorrhage.

A newborn is being admitted to the intensive care unit with the diagnosis of postterm infant. Which nursing actions would be the priority? Select all that apply A) Monitor for hematocrit levels. B) Assess for jaundice. C)Initiate blood glucose monitoring. D) Check for Rh incompatibility. E) Observe for hypothermia.

a,b,c Rationale: Postterm infants will need to be monitored closely for alterations in blood glucose levels. The nurse should also closely assess the postterm infant for polycythemia, which contributes to hyperbilirubinemia, so jaundice would be an indicator. Hct levels will be monitored for the risk of polycythemia. RH factor is not a priority. Temperature monitoring is a standard for all newborn care.

A nurse is preparing to teach a class to pregnant women about the signs of preterm labor and what to do if these occur. Which signs of preterm labor should the nurse include in the presentation? Select all that apply. A)uterine contractions, cramping, low back pain B) feeling of pelvic pressure or fullness C) increase in vaginal discharge D) nausea, vomiting, and diarrhea E) feelings of stress F) leaking of fluid from the vagina

a,b,c,d,f Rationale: Signs and symptoms of preterm labor include uterine contractions, cramping, or low back pain; feeling of pelvic pressure or fullness; increased vaginal discharge; nausea, vomiting, and diarrhea; and leaking of fluid from the vagina.

A primigravida at 28 weeks' gestation comes to the clinic for a check-up. She tells the nurse that her mother gave birth to both of her children prematurely, and she is afraid that the same will happen to her. Which risk factors associated with preterm birth would the nurse discuss with the client? Select all that apply. A) history of previous preterm birth B)current multiple gestation pregnancy C)large-for-gestational age fetus D) uterine or cervical abnormalities E) previous cesarean birth

a,b,d Rationale: The top three risk factors for premature birth are history of previous preterm birth, current multiple gestation pregnancy, and uterine or cervical abnormalities.

Which findings would lead the nurse to suspect that a postpartum woman has developed metritis? Select all that apply. A)pain on both sides of the abdomen B)foul-smelling lochia C) hematuria D)flank pain E) leukocytosis

a,b,e Rationale: Signs and symptoms of metritis include lower abdominal tenderness or pain on one or both sides, foul-smelling lochia, and leukocytosis. Hematuria and flank pain would be associated with a urinary tract infection.

What is a risk factor for developing a postpartum infection? Select all that apply. A) diabetes type 1 B) thin build C) prolonged labor D) cesarean birth E)rupture of membranes at time of birth

a,c,d Rationale: Several risk factors make it more likely for a postpartal woman to develop a wound infection. They include prolonged labor, prolonged ruptured membranes, obesity, history of chronic illnesses such as diabetes or hypertension, and a surgical incision from a cesarean birth. Hematomas and chorioamnionitis also are contributory factors.

The nurse suspects that a postpartum mother is experiencing uterine atony. What physical findings would the nurse note in this client that would validate the suspicion? Select all that apply. A)Boggy fundus B) Urinary output of 50 mL over the last hour C) Fundus located above the umbilicus D) Heavy lochia E)Deep pelvic pain unrelieved by comfort measures

a,c,d Rationale: When a woman experiences uterine atony, the uterus fails to contract back down after delivery. Common symptoms are a boggy fundus, fundal height above the umbilicus, and moderate to heavy lochia. A full bladder can also interfere with uterine contraction. A UOP of 50 mL is adequate and does not play a role in atony. Deep pelvic pain is indicative of a deep pelvis hematoma, not uterine atony.

A 24-hour-old, full-term, small-for-gestational-age neonate is being assessed. Which maternal factors would the nurse correlate with this gestational age variation? Select all that apply. A)blood pressure baseline of 140/90 mm Hg B) maternal age of 30 C) positive for TORCH infections D)hemoglobin 7g/dL E) BMI under 17 F)Rh incompatability

a,c,d,e Rationale: Factors that can contribute to the birth of an SGA newborn are dependent on genetic, placental, and maternal factors such as anemia, intrauterine viral infection, hypertension, and TORCH infections. Blood pressure of 140/90 mm Hg in a pregnant woman as a baseline warrants intervention. The BMI is very low for pregnancy, and the anemia is noted with a hemoglobin of 7g/dL. Rh incompatibility is not a factor in SGA.

The nurse caring for a small for gestational age newborn in the special care nursery. What characteristics are commonly documented? Select all that apply. A) Poor skin turgor B)Tight and moist skin C) Sparse or absent hair D)Narrow skull sutures E)Diminished muscle tissue F)increased fatty tissue

a,c,e Rationale: Characteristics of the small for gestational age newborn include poor skin turgor, loose and dry skin, sparse or absent hair, wide skull sutures caused by inadequate bone growth, and diminished muscle and fatty tissue. Weight, length, and head circumference are below normal expectations as defined on growth charts.

A client just gave birth to a preterm baby in the 30th week of gestation. Which nursing measures does the nurse acticipate for this newborn? Select all that apply. A) Dress the baby in a stockinette cap. B)Carry and handle the baby frequently. C)Place the baby under isolette care. D) Dress the baby to keep the body warm E)Estimate the urinary flow by weighing the diaper.

a,c,e Rationale: The nurse should dress the baby in a stockinette cap, place the baby under isolette care, and estimate the urinary flow by weighing the diaper. Controlling the temperature in high-risk newborns is often difficult; therefore, special care should be taken to keep these babies warm by dressing then in a stockinette cap and recording their temperature on a regular basis. Isolette care simulates the uterine environment as closely as possible, thus maintaining even levels of temperature, humidity, and oxygen for the newborn. The isolette is transparent, so the newborn is visible at all times. The kidneys of preterm infants are not fully developed; hence, they may have difficulty eliminating wastes. The nurse should determine accurate output by weighing the diaper before and after the infant urinates. The diaper's weight difference in grams is approximately equal to the number of milliliters voided. Frequently carrying and handling the baby should be avoided so that the infant can conserve energy. Generally, preterm newborns in the high-risk category are not dressed, so the attending nurse can observe their breathing.

The police have brought a young female to the emergency department after they raided a "crack" house and found this female passed out and bleeding from her "bottom." This female is pregnant and is likely bleeding related to which complication of cocaine use during pregnancy? Select all that apply A) premature dislodgement of the placenta B)rupture of cervical lesions C) rupture of uterus D)dislodgement of fibroid cysts E) spontaneous miscarriage

a,e Rationale: Cocaine, particularly in crack form, is potentially harmful to a fetus because it causes severe vasoconstriction in the mother, thus compromising placental blood flow and perhaps dislodging the placenta. Its use is associated with spontaneous miscarriage, preterm labor, meconium staining, and intrauterine growth restriction. Cocaine is not associated with development of cervical lesions, rupture of uterus, or dislodgement of fibroid cysts.

Which strategies is the nurse correct to utilize when attempting to awaken a potentially sleeping fetus? Select all that apply. A) Lay the mother on the left side B) Clap near the mother's abdomen C)Provide the mother a cold beverage D) Place hands on the abdomen to move the fetus E) Use vibroacoustic stimulation

b,c,d,e Rationale: The nurse is correct to arouse the fetus in a variety of ways. The nurse can use audio stimulation such as clapping near the abdomen or using vibroacoustic stimulation. Providing the mother a cold beverage can also arouse the fetus. Feeling the mother's abdomen for the location of the fetus and moving the body parts can also cause the fetus to move and/or kick. Simply laying the mother on her side may cause a shift in the fetus but is not always enough to arouse the fetus.

A nurse is conducting a teaching program for pregnant woman who are older than age 35. The nurse explains that although most women in their age group have healthy pregnancies and healthy newborns, they are at increased risk for possible complications. Which complications would the nurse include? Select all that apply. A) type 1 diabetes B) postpartum hemorrhage C)preterm labor D)abruptio placentae E) preeclampsia

b,c,e RAtionale: Numerous studies have shown that increasing maternal age is a risk factor for infertility and spontaneous abortions, gestational diabetes, chronic hypertension, postpartum hemorrhage, preeclampsia, preterm labor and birth, multiple pregnancy, genetic disorders and chromosomal abnormalities, placenta previa, fetal growth restriction, low Apgar scores, and surgical births

The pregnant mother and her partner ask the nurse why the health care provider chose a chorionic villus sampling (CVS) procedure over an amniocentesis. The nurse is correct to highlight which benefits of CVS over amniocentesis. Select all that apply. A) Less cost B) Quicker results C)Less procedural discomfort D)Able to be completed earlier in pregnancy E) Less potential complications

b,d Rationale: Chorionic villus sampling is a procedure similar to amniocentesis that provides chromosomal studies of fetal cells. CVS can be completed earlier in pregnancy with the results returning earlier, in 7 to 10 days. Cost factors are similar. Both procedures may have some associated discomfort.

A nurse is assessing a newly admitted newborn who is 2 hours old. Which assessment findings would concern the nurse? Select all that apply. A) The newborn is pink except for the hands and feet, which are blue. B)The newborn has visible bilateral nasal flaring. C) The newborn responds little to voices. D) The newborn has visible chest retractions. E)The newborn has an apical pulse between 140 and 156.

b,d Rationale: The signs and symptoms of respiratory distress include tachypnea, periodic breathing, apnea, retractions, nasal flaring, grunting, pallor, and cyanosis. These findings require interventions. The blue hands and feet, apical pulse rate, and minimal response to voices are all appropriate for a newborn who is two hours old.

The nurse is required to assess a client for HELLP syndrome. Which are the signs and symptoms of this condition? Select all that apply. A) blood pressure higher than 160/110 mm Hg B) epigastric pain C) oliguria D) upper right quadrant pain E) hyperbilirubinemia

b,d,e Rationale: The signs and symptoms of HELLP syndrome are nausea, malaise, epigastric pain, upper right quadrant pain, demonstrable edema, and hyperbilirubinemia. Blood pressure higher than 160/110 mm Hg and oliguria are the symptoms of severe preeclampsia rather than HELLP syndrome.

When planning the care for a small for gestational age (SGA) newborn, which action would the nurse determine as a priority? A) Preventing hypoglycemia with early feedings B) Observing for respiratory distress syndrome C) Promoting bonding between the parents and the newborn D)Monitoring vital signs every 2 hours

a Rationale: With the loss of the placenta at birth, the newborn must now assume control of glucose homeostasis. This is achieved by early oral intermittent feedings. Observing for respiratory distress, promoting bonding, and monitoring vital signs, although important, are not the priority for this newborn.

Which nursing interventions are provided to the newborn utilizing phototherapy via a fiberoptic blanket? Select all that apply. A)Assess the newborn's skin. B)Increase fluid intake. C)Maintain protective cover around infant. D)Remove the infant to feed and change. E) Cover the newborn's eyes.

a,b,c,d Rationale: Nursing interventions are different when utilizing phototherapy lights and a fiberoptic blanket. The main difference is that the fiberoptic blanket does not require the newborn to maintain eye shields. All the other options are correct.

The nurse is completing accurate output on a preterm client. The nurse changed the client's diaper, which weighs 50 g. The dry diaper weighs 22 g. Which amount does the nurse record under output? Record your answer using a whole number.

28 Rationale: One gram equals approximately 1 mL. The wet diaper and dry diaper are weighed. The weight of the dry diaper is subtracted from the weight of the wet one. 50 mL - 22 mL = 28 mL

A woman is to undergo labor induction. The nurse determines that the woman requires cervical ripening if her Bishop score is: A)5 B)6 C)7 D)9

A Rationale: A Bishop score less than 6 usually indicates that a cervical ripening method should be used before labor induction.

The health care provider (HCP) prescribes a maternal blood test for alpha fetoprotein for a nulligravid client at 16 weeks' gestation. When developing the teaching plan, the nurse bases the explanations on the understanding that this test is used to detect which condition? A) neural tube defects B)Rh incompatibilities C)inborn errors of metabolism D)Lecithin-sphingomyelin ratio

A Rationale: A blood test for alpha fetoprotein is recommended at 15 to 20 weeks' gestation to screen for certain chromosomal abnormalities and neural tube defects such as spina bifida. Chorionic villi sampling is used to detect chromosomal anomalies. Amniotic fluid amino acid determination is used to detect inborn errors of metabolism such as phenylketonuria. An amniocentesis is used to determine the lecithin-sphingomyelin ratio for fetal lung maturity, indicated by a ratio of 2:1, or chromosomal abnormalities. Rh incompatibilities are predicted with blood type testing measured with antigen tests.

During routine prenatal screening, a nurse tells a client that her blood sample will be used for alpha fetoprotein (AFP) testing. Which statement best describes what AFP testing indicates? A)"This test will show if you have gestational diabetes." B) "This test will screen for spina bifida, Down syndrome, or other genetic defects." C) "This screening indicates if your baby's lungs are mature." D) "To provide accurate results, this screening must be performed exactly at 25 weeks' gestation."

B Rationale: AFP testing screens for spina bifida, Down syndrome, and other genetic defects. It must be performed at 16 to 18 weeks' gestation to provide accurate results. A 1-hour glucose tolerance test diagnoses gestational diabetes. Amniocentesis assesses the maturity of fetal lungs

A 38-year-old client, G4P3, at 10 weeks' gestation with an unplanned pregnancy, has concerns the fetus may have a genetic defect. The nurse should point out which test would be the best current choice to investigate the possibility of a chromosomal abnormality? A) Amniocentesis B)Chorionic villus sampling C) Maternal Serum Alpha-fetoprotein D) Triple screening

B Rationale: Chorionic villus sampling is the earliest method (8 to 10 weeks gestation) to test the fetal genetics for anomalies. This testing might be offered if the mother wants specific information on the genetics of the fetus as early as possible in pregnancy. Amniocentesis is generally done between 14 and 18 weeks' gestation, but can be done as early as 10 weeks' gestation. Maternal serum alpha-fetoprotein are usually done at 16 to 20 weeks' gestation, and triple screening is performed between 15 and 20 weeks' gestation.

After conducting a refresher class on possible congenital infections with a group of perinatal nurses, the nurse recognizes the class was successful when the group identifies which congenital viral infection as the most common? A)CMV B)HIv C)HPV D)RSV

a Rationale: Cytomegalovirus (CMV) is the most common congenital and perinatal viral infection in the world. Human immunodeficiency virus (HIV), human papillomavirus (HPV), and herpes simplex virus (HSV) are other potential viruses.

A G2P1 woman is in labor attempting a VBAC, when she suddenly complains of light-headedness and dizziness. An increase in pulse and decrease in blood pressure is noted as a change from the vital signs obtained 15 minutes prior. The nurse should investigate further for additional signs or symptoms of which complication? A) Uterine rupture B) Hypertonic uterus C) Placenta previa D) Umbilical cord compression

a Rationale: The client with any prior history of uterus surgery is at increased risk for a uterine rupture. A falling blood pressure and increasing pulse is a sign of hemorrhage, and in this client a uterine rupture needs to be a first consideration. The scenario does not indicate a hypertonic uterus, a placenta previa, or umbilical cord compression.

A nurse is assessing a preterm newborn for possible sepsis. The nurse suspects an early onset infection based on which risk factors? Select all that apply. A)preterm labor B) prolonged rupture of membranes C) immaturity of the immune system D)decreased gastric acid E) maternal fever

a.b,e Rationale: Risk factors for early onset neonatal infection include preterm labor, prolonged rupture of membranes, and maternal fever. An immature immune system and decreased gastric acid are risk factors for intrauterine infection.

A multigravida client at 31 weeks' gestation is admitted with confirmed preterm labor. As the nurse continues to monitor the client now receiving magnesium sulfate, which assessment findings will the nurse prioritize and report immediately to the RN or health care provider? A) Low potassium or elevated glucose, tachycardia, chest pain B)Respiratory depression, hypotension, absent tendon reflexes C)Severe lower back pain, leg cramps, sweating D)Pain in the abdomen, shoulder, or back

b Rationale: Magnesium sulfate is a smooth muscle relaxant and can cause vasodilation and results in respiratory depression and severe hypotension at toxic levels. The other options are incorrect indications of magnesium sulfate toxicity.

The nurse is caring for a client after experiencing a placental abruption. Which finding is the priority to report to the health care provider? A) hematocrit of 36% B) 45 ml urine output in 2 hours C)hemoglobin of 13 g/dl D) platelet count of 150,000 mm3

b Rationale: The nurse knows a placental abruption places the client at high risk of hemorrhage. A decreased urine output indicates decreased perfusion from blood loss. The hematocrit, hemoglobin, and platelet counts are all within expected levels.

What criteria would the physician base his decision on to begin insulin therapy for a gestational diabetic mother? A) Client cannot keep fasting blood sugar lower than 90 mg/dL. B)Urine is 2+ for glucose and serum blood glucose is 120. C) A 2-hour postprandial glucose level cannot be kept below 120 mg/dL. D) Weight gain is over 30 pounds (13.6 kg) and blood sugars are fluctuating between 95 and 130 throughout the day.

c Rationale: A physician usually recommends beginning a woman with gestational diabetes on insulin therapy when exercise and diet are ineffective and if she is unable to keep her fasting blood sugar levels below 95 mg/dL or her 2-hour postprandial glucose levels below 120 mg/dL.

Shoulder dystocia is a true medical emergency that can cause fetal demise because the baby cannot be born. Stuck in the birth canal, the infant cannot take its first breath. Which maneuver is first attempted to deliver an infant with shoulder dystocia? A) McDonald maneuver B) McGeorge maneuver C) McRoberts maneuver D)McRonald maneuver

c Rationale: McRoberts maneuver is an intervention that is frequently successful in cases of shoulder dystocia, and it is often tried first. McRoberts requires the assistance of two individuals. Two nurses are ideal; however, a support person or a technician can serve as the second assistant. With the woman in lithotomy position, each nurse holds one leg and sharply flexes the leg toward the woman's shoulders. This opens the pelvis to its widest diameters and allows the anterior shoulder to deliver in almost half of the cases.

A nurse is caring for a large-for-gestational-age newborn. Which signs would lead the nurse to suspect that the newborn is experiencing hypoglycemia? Select all that apply. A) Bulging fontanels B)High-pitched, shrill cry C)Lethargy and stupor D) Respiratory difficulty E)Appearance of central cyanosis

c,d,e Rationale: The features indicating hypoglycemia in large for gestational (LGA) infants include lethargy, stupor, fretfulness, respiratory difficulty, and central cyanosis. The other features include poor feeding in a previously well feeding infant and weak, whimpering cry. High-pitched, shrill cry and bulging fontanels are seen in increased intracranial pressure following head trauma in LGA infants.

A nurse is assessing pregnant clients for the risk of placenta previa. Which client faces the greatest risk for this condition? A) a 23-year-old multigravida client B)a client with a history of alcohol abuse C)a client with a structurally defective cervix D) a client who had a myomectomy to remove fibroids

d Rationale: A previous myomectomy to remove fibroids can be associated with the cause of placenta previa. Risk factors also include advanced maternal age (greater than 30 years old). A structurally defective cervix cannot be associated with the cause of placenta previa. However, it can be associated with the cause of cervical insufficiency. Alcohol ingestion is not a risk factor for developing placenta previa but is associated with abruption placenta.

A client has been admitted to the critical care unit with a diagnosis of thyroid storm. What interventions should the nurse include in this client's immediate care? Select all that apply. A) Administering diuretics to prevent fluid overload B)Administering beta blockers to reduce heart rate C) Administering insulin to reduce blood glucose levels D)Applying interventions to reduce the client's temperature E) Administering corticosteroids

B,D Rationale:Thyroid storm necessitates interventions to reduce heart rate and temperature. Diuretics, insulin, and steroids are not indicated to address the manifestations of this health problem.

The nurse is caring for a near-term pregnant woman who has not taken prenatal vitamins or folic acid supplements. Which congenital defect is most likely to occur based on the mother's prenatal history? A)Neonatal conjunctivitis B)Facial deformities C)A neural tube defect D)Incomplete myelinization

C Rationale: Folic acid supplementation has been found to reduce the incidence of neural tube defects by 50%. The fact that the mother has not used folic acid supplements puts her baby at risk for spina bifida occulta, one type of neural tube defect. Neonatal conjunctivitis can occur in any newborn during birth and is caused by virus, bacteria, or chemicals. Facial deformities are typical of babies of alcoholic mothers. Incomplete myelinization is present in all newborns.

What interventions can the nurse encourage the client with diabetes insipidus to do in order to control thirst and compensate for urine loss? A) Come to the clinic for IV fluid therapy daily. B)Limit the fluid intake at night. C)Consume adequate amounts of fluid. D)Weigh daily.

C Rationale: The nurse teaches the client to consume sufficient fluid to control thirst and to compensate for urine loss. The client will not be required to come in daily for IV fluid therapy. The client should not limit fluid intake at night if thirst is present. Weighing daily will not control thirst or compensate for urine loss.

A client is admitted to the unit in preterm labor. In preparing the client for this therapy, the nurse anticipates that the client's pregnancy may be prolonged for how long when this therapy is used A) 2 to 7 days B) 1 to 5 days C) 6 to 10 days D) 4 to 8 days

A Rationale:Tocolytic drugs may prolong the pregnancy for 2 to 7 days. During this time, steroids can be given to improve fetal lung maturity, and the woman can be transported to a tertiary care center.

The child may have developed thyroid storm. Which clinical manifestations of thyroid storm should the nurse expect to find? Select all that apply. A)Temperature of 103.2° F (39.6° C) B)Wet bed linen and report of feeling "sweaty" C) Apical heart rate of 172 beats per minute D)Report of feeling very tired and wanting to nap E)Mild-mannered and compliant demeanor

A,B,C Rationale: Signs and symptoms related to the development of thyroid storm include: fever, diaphoresis, and tachycardia. Children with thyroid storm are typically restless and irritable.

A client is admitted for treatment of the syndrome of inappropriate antidiuretic hormone (SIADH). Which nursing intervention is appropriate? A) Infusing I.V. fluids rapidly as ordered B)Encouraging increased oral intake C)Restricting fluids D)Administering glucose-containing I.V. fluids as ordered

C Rationale: To reduce water retention in a client with the SIADH, the nurse should restrict fluids. Administering fluids by any route would further increase the client's already heightened fluid load.

A 25-year-old female client is diagnosed with hypothyroidism. The client is prescribed levothyroxine. Which instruction about the administration of this medication would be important? A)She should take the medication when she takes her other morning medications. B) She should take the medication with grapefruit juice to promote absorption. C)She should take the medication in the morning before breakfast. D)She should take the medication at dinner time.

C Rationale: Levothyroxine interacts with many drugs. Many drugs interfere with its absorption, resulting in decreased serum concentration. Coadministration with levothyroxine should be separated by several hours. Levothyroxine is best taken as a single daily dose before breakfast. Assist the patient to establish a routine for taking the medication. Assess the patient's intake of grapefruit juice; excessive grapefruit juice may delay the absorption of levothyroxine.

You are caring for a patient who has a diagnosis of syndrome of inappropriate antidiuretic hormone secretion (SIADH). Your patient's plan of care includes assessment of specific gravity every 4 hours. The results of this test will allow the nurse to assess what aspect of the patient's health? A) Nutritional status B)Potassium balance C)Calcium balance D) Fluid volume status

D Rationale: A specific gravity will detect if the patient has a fluid volume deficit or fluid volume excess. Nutrition, potassium, and calcium levels are not directly indicated.

A nurse is caring for a newborn with transient tachypnea. Which is the priority nursing intervention? A) Administer IV fluids; gavage feedings. B) Maintain adequate hydration. C) Monitor for signs of hypotonia. D) Perform gentle suctioning.

a Rationale: The nurse should administer IV fluids and gavage feedings until the respiratory rate decreases enough to allow oral feedings when caring for a newborn with transient tachypnea. Maintaining adequate hydration and performing gentle suctioning are relevant nursing interventions when caring for a newborn with respiratory distress syndrome. The nurse need not monitor the newborn for signs and symptoms of hypotonia because hypotonia is not known to occur as a result of transient tachypnea. Hypotonia is observed in newborns with inborn errors of metabolism or in cases of periventricular hemorrhage/intravenricular hemorrhage.

The nurse is caring for a client who is having a high risk pregnancy and requires genetic studies. Which procedures will the nurse anticipate? Select all that apply. A) Amniocentesis B) Maternal serum alpha-fetoprotein screening C) Chorionic villus sampling D) Percutaneous umbilical blood sampling E)Ultrasonography

a,c,d Rationale: The nurse is most correct to anticipate either an amniocentesis or chorionic villus sampling as the primary tests for genetic testing. Percutaneous umbilical blood sampling can also be used to determine genetically linked blood diseases such as von Willebrand disease. Maternal serum alpha-fetoprotein screen is completed to screen for neural tube defects. Ultrasonography is a noninvasive procedure showing fetal images and movement.

The nurse is educating a client with type 1 diabetes about the complications associated with diabetes and pregnancy. Which problems would the nurse include in her teaching? Select all that apply. A) Decreased birth weight B) Increased risk of spontaneous abortion C) Polyhydramnios D) Hypertension E) Cystic fibrosis

b,c,d Rationale: Women with pregestational diabetes, which is type 1 diabetes, are at a higher risk of having an infant with complications during the pregnancy and at delivery. Spontaneous abortion is higher in women who have pregestational diabetes. Also, they run a higher risk of having a pregnancy with polyhydramnios, and of developing maternal hypertension. The birth weight of an infant born to a mother with diabetes is increased, not decreased. Cystic fibrosis is not associated with maternal diabetes.

A graduate nurse (GN) is caring for a woman being inducted via oxytocin infusion. The client is currently reporting a headache and is vomiting. The graduate nurse thinks that the client is getting near the end of labor. However, the GNs preceptor intervenes by performing which interventions immediately after hearing this report? SATA A) administering IV ondansetron for the nausea/vomiting B) discontinuing the oxytocin infusion C) increasing IV fluid rate D)notifying the health care provider immediately E)calling respiratory therapy to obtain ABGs on this client

b,d Rationale: A second side effect of oxytocin is that it can result in decreased urine flow, possibly leading to water intoxication. This is first manifested by headache and vomiting. If the nurse observes these danger signs in a woman during induction of labor, she should report them immediately and halt the infusion. Ondansetron may be appropriate but is not the priority. The headache and vomiting is due to water intoxication, so fluids should be decreased not increased. At this point, ABGs are not the priority intervention

A postpartal woman is developing a thrombophlebitis in her right leg. Which assessment would the nurse use to assess for thrombophlebitis? Select all that apply. A) Assess for redness and warmth in the affected leg. B)Ask if her pain that is relieved with walking. C) Assess for edema in the affected leg. D) Assess for a low-grade fever.

a,c,d Rationale: The nurse should ask the woman if she has pain or tenderness in the lower extremities when ambulating that is relieved by rest and elevation. Also assess for redness, warmth, and edema as well as a low-grade fever.

A client has sustained a traumatic brain injury with involvement of the hypothalamus. The nurse is concerned about the development of diabetes insipidus. Which of the following would be an appropriate nursing intervention to monitor for early signs of diabetes insipidus? A) Take daily weights. B) Reposition the client frequently. C) Assess for pupillary response frequently. D) Assess vital signs frequently

A Rationale: A record of daily weights is maintained for the client with a traumatic brain injury, especially if the client has hypothalamic involvement and is at risk for the development of diabetes insipidus. A weight loss will alert the nurse to possible fluid imbalance early in the process.

The neonatal nurse is admitting a 37 weeks' gestation infant of a mother with poorly controlled gestational diabetes. Which laboratory test results would the nurse expect to find? Select all that apply. A)hypocalcemia B) hypermagnesemia C) polycythemia D)hypobilirubinemia E)hypoglycemia

a,c,e Rationale: Laboratory and diagnostic testing of a newborn of a diabetic mother are monitored for hypoglycemia, hypocalcemia, hypomagnesemia, and hyperbilirubinemia. Polycythemia is also monitored for with a venous hematocrit level increase.

A nursing student working with a client in preterm labor correctly identifies which medication as being used to relax the smooth muscles of the uterus and for seizure prophylaxis and treatment in clients with preeclampsia? A) betamethasone B) magnesium sulfate C)indomethacin D)nifedipine

b Rationale: The drug used to relax the uterine muscles and for seizure prophylaxis is magnesium sulfate. Betamethasone promotes fetal lung maturity, indomethacin inhibits uterine activity to arrest preterm labor, and nifedipine blocks calcium movement into the muscle cells and inhibits preterm labor.

A pregnant woman comes to the birthing center, stating she is in labor and does not know far along her pregnancy is because she has not had prenatal care. A primary care provider performs an ultrasound that indicates oligohydramnios. When the client's membranes rupture, meconium is in the amniotic fluid. What does the nurse suspect may be occurring with this client? A) complications of a postterm pregnancy B)complications of preterm labor C)complications of placenta previa D)placental abruption

A Rationale: A postterm pregnancy carries risks for increased perinatal mortality, particularly during labor. Oligohydramnios and meconium staining of the amniotic fluid are common complications. Oligohydramnios increases the incidence of cord compression, which can lead to fetal distress during labor. Thick, meconium-stained fluid increases the risk for meconium aspiration syndrome.

Various medications are available to help control hemorrhage in the postpartum client. When reviewing the client's history, the nurse notes she has a history of asthma. Which medication would be contraindicated in her case? A) carboprost B) oxytocin C) misoprostol D) methylergonovine

A Rationale: Carboprost is contraindicated with asthma due to the risk of bronchial spasms. Oxytocin should be given undiluted as a bolus injection, misoprostol should not be given to women with active CVD, pulmonary or hepatic disease, and methylergonovine should not be given to a woman who is hypertensive.

After undergoing a thyroidectomy, a client develops hypocalcemia and tetany. The nurse knows that this may be the result of what complication of the surgery A) Damage to the parathyroid glands B)Damage to the recurrent laryngeal nerve C) The effects of hemorrhage D)The effects of airway edema

A Rationale: Damage to the parathyroid glands may cause hypocalcemia. Damage to the recurrent laryngeal nerve may cause voice loss. Hemorrhage may compromise the airway, as will edema, but neither will result in hypocalcemia.

Which of the following endocrine disorder causes the patient to have dilutional hyponatremia? A) Syndrome of inappropriate antidiuretic hormone secretion (SIADH) B)Diabetes insipidus (DI) C)Hypothyroidism D)Hyperthyroidism

A Rationale: Patients diagnosed with SIADH retain water and develop a subsequent sodium deficiency known as dilutional hyponatremia. In DI, there is excessive thirst and large volumes of dilute urine. Patients with DI, hypothyroidism, or hyperthyroidism do not exhibit dilutional hyponatremia

The nurse is caring for several postpartum clients and notes various warning signs that are concerning. Which client should the nurse suspect is developing endometritis? A)A woman with diabetes, vaginal birth, HR 110, temperature 101.7° F (38.7° C) on the third postpartum day. The next day, appears ill; temperature now 102.9° F (39.3° C); WBC 31,500 cells/mm&$176;3; negative blood cultures. B)A woman with a history of infection and smoking, temperature 101° F (38.3° C) on the fourth postpartum day; reports severe perineal pain; edges of the episiotomy have separated. C)An obese woman with temperature 100.4° F (38° C) at 12 hours after birth; lochia is moderate; negative vaginal cultures. D)A woman with PROM before birth; reports severe burning with urination, malaise and severe temperature spikes on the 7th postpartum day. WBC is 21,850 cells/mm&$176;3; temperature 101° F (38.3° C); skin pale and clammy.

A rationale: Endometritis is an infection of the endometrium of the uterus. Clinical manifestations include a fever of 100.4°F (38°C) or higher, usually between the 2nd and 10th day after delivery; tachycardia, chills, anorexia, and general malaise; client may also report abdominal cramping and pain. Complaints of severe perineal pain and signs of fever and separation of the episiotomy edges would be suspicious for a wound infection. An elevated temperature of up to 100.4°F (38°C) within the first 24 hours is a normal response to the birthing process. Reports of severe burning on urination accompanied by fever and malaise would be suspicious of a UTI.

What pharmacologic therapy does the nurse anticipate administering when the patient is experiencing thyroid storm? (Select all that apply.) A) Acetaminophen B) Iodine C) Propylthiouracil D) Synthetic levothyroxine E)Dexamethasone (Decadron)

A,B,C Rationale: Treatments for thyroid storm include the following: a hypothermia mattress or blanket, ice packs, a cool environment, hydrocortisone, and acetaminophen (Tylenol); propylthiouracil (PTU) or methimazole to impede formation of thyroid hormone and block conversion of T4 to T3, the more active form of thyroid hormone; and iodine, to decrease output of T4 from the thyroid gland.

During an assessment of a patient with SIADH, the nurse notes the unexpected result of: A) Moist mucous membranes. B)Pitting edema in the lower extremities. C)A blood pressure reading of 120/85 mm Hg. D)Normal skin turgor.

B Rationale: In SIADH, the patient does not appear to retain fluids because reabsorbed water is intracellular rather than interstitial.

A patient with a history of hypothyroidism is admitted to the intensive care unit unconscious and with a temperature of 95.2ºF. A family member informs the nurse that the patient has not taken thyroid medication in over 2 months. What does the nurse suspect that these findings indicate? A)Thyroid storm B) Myxedema coma C)Diabetes insipidus D)Syndrome of inappropriate antidiuretic hormone (SIADH)

B Rationale: Myxedema coma is a rare life-threatening condition. It is the decompensated state of severe hypothyroidism in which the patient is hypothermic and unconscious (Ross, 2012a). This condition may develop with undiagnosed hypothyroidism and may be precipitated by infection or other systemic disease or by use of sedatives or opioid analgesic agents. Patients may also experience myxedema coma if they forget to take their thyroid replacement medication.

The physician has ordered a fluid deprivation test for a client suspected of having diabetes insipidus. During the test, the nurse should prioritize what assessments? A) Temperature and oxygen saturation B)Heart rate and blood pressure C)Breath sounds and bowel sounds D)Color, warmth, movement, and sensation of extremities

B Rationale: The fluid deprivation test is carried out by withholding fluids for 8 to 12 hours or until 3% to 5% of the body weight is lost. The client's condition needs to be monitored frequently during the test, and the test is terminated if tachycardia, excessive weight loss, or hypotension develops. Consequently, blood pressure and heart rate monitoring are priorities over the other listed assessments. Reference:

What will be the nurse's next action after noting dimpling and a tuft of hair located in the lumbosacral area of the preschool child during examination? A)Snip the tuft of hair off close to the skin for hygienic reasons B)Move on to other assessments without calling attention to the difference C) Record and refer the finding for follow-up to the pediatrician D)Inspect for precocious hair growth in the genital and underarm areas

C Rationale: Dimpling and hair growth may signal spina bifida occulta, which usually is benign. However, some complications can be associated, and further investigation is warranted to prevent possible damage to the spinal cord. Magnetic resonance imaging (MRI) is often the diagnostic tool used. No hygienic concerns need prevail. These findings do not suggest development of precocious puberty or any other hormonal problem. The dimpling and hair tuft must be clearly explained to the parents.

A nurse caring for a patient with diabetes insipidus is reviewing laboratory results. What is an expected urinalysis finding? A) Glucose in the urine B) Albumin in the urine C)Highly dilute urine D)Leukocytes in the urine

C Rationale: Patients with diabetes insipidus produce an enormous daily output of very dilute, water-like urine with a specific gravity of 1.001 to 1.005. The urine contains no abnormal substances such as glucose or albumin. Leukocytes in the urine are not related to the condition of diabetes insipidus, but would indicate a urinary tract infection, if present in the urine.

An incoherent client with a history of hypothyroidism is brought to the emergency department by the rescue squad. Physical and laboratory findings reveal hypothermia, hypoventilation, respiratory acidosis, bradycardia, hypotension, and nonpitting edema of the face and periorbital area. Knowing that these findings suggest severe hypothyroidism, the nurse prepares to take emergency action to prevent the potential complication of: A) thyroid storm. B) cretinism. C) myxedema coma. D)Hashimoto's thyroiditis.

C Rationale: Severe hypothyroidism may result in myxedema coma, in which a drastic drop in the metabolic rate causes decreased vital signs, hypoventilation (possibly leading to respiratory acidosis), and nonpitting edema. Thyroid storm is an acute complication of hyperthyroidism. Cretinism is a form of hypothyroidism that occurs in infants. Hashimoto's thyroiditis is a common chronic inflammatory disease of the thyroid gland in which autoimmune factors play a prominent role.

An obstetric ultrasound reveals that the client's fetus has spina bifida. The mother is concerned about raising a child with a congenital abnormality and she starts to cry. Which response by the nurse is best? A) Recommend elective termination of the pregnancy. B)Recommend a pediatrician because the baby will be sick. C)Sit at her bedside and allow the client to express her feelings. D)Discuss the risk of dystocia with vaginal births.

C Rationale: The mother has just been given unexpected news. The nurse should provide emotional support by sitting with the client and allowing her to express her feelings and concerns. The nurse shouldn't tell a client what to do. The client needs information to make her own informed decision. Recommending a pediatrician is premature because the client just received the ultrasound results. The nurse shouldn't discuss birth at this time. The preferred birth method for a fetus with spina bifida is cesarean birth, which prevents damage to the open spinal cord defect as the fetus descends through the birth canal.

What should the nurse suspect when hourly assessment of urine output on a patient postcraniotomy exhibits a urine output from a catheter of 1,500 mL for two consecutive hours? A) Cushing syndrome B)Syndrome of inappropriate antidiuretic hormone (SIADH) C)Adrenal crisis D) Diabetes insipidus

D Rationale Diabetes insipidus is an abrupt onset of extreme polyuria that commonly occurs in patients after brain surgery. Cushing syndrome is excessive glucocorticoid secretion resulting in sodium and water retention. SIADH is the result of increased secretion of ADH; the patient becomes volume-overloaded, urine output diminishes, and serum sodium concentration becomes dilute. Adrenal crisis is undersecretion of glucocorticoids resulting in profound hypoglycemia, hypovolemia, and hypotension.

A nurse finds that a client is bleeding excessively after a vaginal birth. Which assessment finding would indicate retained placental fragments as a cause of bleeding? A)soft and boggy uterus that deviates from the midline B)firm uterus with trickle of bright red blood in perineum C)firm uterus with a steady stream of bright red blood D)Large uterus with painless dark red blood mixed with clots

D Rationale: The presence of a large uterus with painless dark red blood mixed with clots indicates retained placental fragments in the uterus. This cause of hemorrhage can be prevented by carefully inspecting the placenta for intactness. A firm uterus with a trickle or steady stream of bright red blood in the perineum indicates bleeding from trauma. A soft and boggy uterus that deviates from the midline indicates a full bladder, interfering with uterine involution.

A nurse is caring for a child with spina bifida. The child's mother asks the nurse what she did to cause the birth defect. Which statement would be the nurse's best response? A) "Older age at conception is one of the major causes of the defect." B) "It's a common complication of amniocentesis." C) "It has been linked to maternal alcohol consumption during pregnancy." D) "The cause is unknown and there are many environmental factors that may contribute to it."

D Rationale: There is no one known cause of spina bifida, but scientists believe that it's linked to hereditary and environmental factors; neural tube defects, including spina bifida, have been strongly linked to low dietary intake of folic acid. Maternal age doesn't have an impact on spina bifida. An amniocentesis is performed to help diagnose spina bifida in utero but doesn't cause the disorder. Maternal alcohol intake during pregnancy has been linked to intellectual disability, craniofacial defects, and cardiac abnormalities, but not spina bifida

The nurse is caring for a patient with hyperthyroidism who suddenly develops symptoms related to thyroid storm. What symptoms does the nurse recognize that are indicative of this emergency? A) Heart rate of 62 B) Blood pressure 90/58 mm Hg C) Oxygen saturation of 96% D) Temperature of 102ºF

D Rationale: Thyroid storm is characterized by the following: 1) high fever (hyperpyrexia), >38.5°C (>101.3°F); 2) extreme tachycardia (>130 bpm); 3) exaggerated symptoms of hyperthyroidism with disturbances of a major system—for example, gastrointestinal (weight loss, diarrhea, abdominal pain) or cardiovascular (edema, chest pain, dyspnea, palpitations); and 4) altered neurologic or mental state, which frequently appears as delirium psychosis, somnolence, or coma.

A nurse is caring for a postpartum client who has been treated for deep vein thrombosis (DVT). Which prescription would the nurse question? A)Wear compression stockings. B) Plan long rest periods throughout the day. C) Take aspirin as needed. D)Take an oral contraceptive daily.

D Rationale: When caring for a client with DVT, the nurse should instruct the client to avoid using oral contraceptives. Cigarette smoking, use of oral contraceptives, sedentary lifestyle, and obesity increase the risk for developing DVT. The nurse should encourage the client with DVT to wear compression stockings. The nurse should instruct the client to avoid using products containing aspirin when caring for clients with bleeding, but not for clients with DVT. Prolonged rest periods should be avoided. Prolonged rest involves staying motionless; this could lead to venous stasis, which needs to be avoided in cases of DVT.