Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
The nurse identifies the following assessment findings in a client who is 36 weeks' gestation. Which should be immediately reported to the provider?
A. O negative blood type
O negative blood type. This is significant for Rh incompatibility if the fetus is Rh-positive, but it is managed through routine prenatal care and does not require immediate intervention at 36 weeks.
B. Blood pressure 144/94 mm/Hg in left arm
Blood pressure 144/94 mmHg in left arm. This finding is concerning because it may indicate the development of preeclampsia, which requires immediate medical attention due to the potential risks to both the mother and fetus.
C. Positive rubella serum antibody titer
Positive rubella serum antibody titer. A positive titer indicates immunity to rubella, which is a good finding in pregnancy and not a concern.
D. Copious leukorrhea
Copious leukorrhea. This is common in late pregnancy and typically not a cause for concern unless it is accompanied by signs of infection or rupture of membranes.
This question is an excerpt from Nurse Dive's nursing test bank - Ati Nur 209 Reproductive Health Proctored Exam. Take the full exam now
Full Explanation
A. O negative blood type. This is significant for Rh incompatibility if the fetus is Rh-positive, but it is managed through routine prenatal care and does not require immediate intervention at 36 weeks.
B. Blood pressure 144/94 mmHg in left arm. This finding is concerning because it may indicate the development of preeclampsia, which requires immediate medical attention due to the potential risks to both the mother and fetus.
C. Positive rubella serum antibody titer. A positive titer indicates immunity to rubella, which is a good finding in pregnancy and not a concern.
D. Copious leukorrhea. This is common in late pregnancy and typically not a cause for concern unless it is accompanied by signs of infection or rupture of membranes.
Similar Questions
A nurse is assessing a newborn who has Trisomy 21 (Down's Syndrome). Which of the following are common characteristics? (Select All that Apply.)
A. Hypertonia
A. Hypertonia Hypertonia, or increased muscle tone, is not a common characteristic of Trisomy 21. In fact, many infants with Down's Syndrome typically exhibit hypotonia, or decreased muscle tone, which can affect their overall strength and development.
B. Large ears
B. Large ears While individuals with Down's Syndrome may have unique ear shapes, "large ears" are not specifically characteristic of Trisomy 21. Instead, the ears may appear small or have a different shape compared to those of typically developing children.
C. Transverse palmar creases
C. Transverse palmar creases Transverse palmar creases, also known as simian lines, are commonly seen in individuals with Down's Syndrome. This feature is a characteristic finding that can help in identifying the condition during physical assessment.
D. Protruding tongue
D. Protruding tongue A protruding tongue is a common feature in individuals with Down's Syndrome. This occurs due to hypotonia of the oral muscles, which can lead to difficulties in tongue control and positioning.
E. Low birth weight
E. Low birth weight Low birth weight is not a defining characteristic of Trisomy 21. In fact, newborns with Down's Syndrome can have varying birth weights; they are often average weight or slightly above average, although some may be below average due to other factors related to maternal health or gestational issues.
Full Explanation
Answer: C, D
A. Hypertonia
Hypertonia, or increased muscle tone, is not a common characteristic of Trisomy 21. In fact, many infants with Down's Syndrome typically exhibit hypotonia, or decreased muscle tone, which can affect their overall strength and development.
B. Large ears
While individuals with Down's Syndrome may have unique ear shapes, "large ears" are not specifically characteristic of Trisomy 21. Instead, the ears may appear small or have a different shape compared to those of typically developing children.
C. Transverse palmar creases
Transverse palmar creases, also known as simian lines, are commonly seen in individuals with Down's Syndrome. This feature is a characteristic finding that can help in identifying the condition during physical assessment.
D. Protruding tongue
A protruding tongue is a common feature in individuals with Down's Syndrome. This occurs due to hypotonia of the oral muscles, which can lead to difficulties in tongue control and positioning.
E. Low birth weight
Low birth weight is not a defining characteristic of Trisomy 21. In fact, newborns with Down's Syndrome can have varying birth weights; they are often average weight or slightly above average, although some may be below average due to other factors related to maternal health or gestational issues.
What assessment finding would the nurse expect in an infant with coarctation of the aorta?
A. Point of maximum impulse is shifted to the right
Point of maximum impulse is shifted to the right. This is not typically associated with coarctation of the aorta, but with other cardiac abnormalities.
B. Weak or absent lower extremity pulses
Weak or absent lower extremity pulses. Coarctation of the aorta causes narrowing of the aorta, which restricts blood flow to the lower body, leading to diminished pulses in the lower extremities.
C. Apical pulse is greater than radial pulse
Apical pulse is greater than radial pulse. This finding is not specifically related to coarctation of the aorta.
D. Systolic murmur at the left sternal border
Systolic murmur at the left sternal border. While murmurs may be present, coarctation typically causes a murmur best heard in the back or left infraclavicular area.
Full Explanation
A. Point of maximum impulse is shifted to the right. This is not typically associated with coarctation of the aorta, but with other cardiac abnormalities.
B. Weak or absent lower extremity pulses. Coarctation of the aorta causes narrowing of the aorta, which restricts blood flow to the lower body, leading to diminished pulses in the lower extremities.
C. Apical pulse is greater than radial pulse. This finding is not specifically related to coarctation of the aorta.
D. Systolic murmur at the left sternal border. While murmurs may be present, coarctation typically causes a murmur best heard in the back or left infraclavicular area.
A 19-year-old goes to Planned Parenthood clinic with complaints of painful lesions, fever, headache, and vaginal discharge. After testing she is diagnosed with Herpes simplex virus type 2. What education should the nurse include in a teaching plan? (Select All that Apply.)
A. Handwashing
Handwashing. Good hygiene is important to prevent the spread of the virus, especially after touching the lesions.
B. Gardasil injection
Gardasil injection. Gardasil is a vaccine for HPV, not HSV. It is not relevant for the management of herpes.
C. Penicillin
Penicillin. Penicillin is not effective against viral infections like herpes; antiviral medications such as acyclovir are used for treatment.
D. Use of barrier protection
Use of barrier protection. Barrier methods such as condoms are crucial in reducing the risk of transmission of HSV-2 to sexual partners.
E. Perineal care of genital lesions
Perineal care of genital lesions. Proper care of lesions can help reduce discomfort and prevent secondary infections.
Full Explanation
A. Handwashing. Good hygiene is important to prevent the spread of the virus, especially after touching the lesions.
B. Gardasil injection. Gardasil is a vaccine for HPV, not HSV. It is not relevant for the management of herpes.
C. Penicillin. Penicillin is not effective against viral infections like herpes; antiviral medications such as acyclovir are used for treatment.
D. Use of barrier protection. Barrier methods such as condoms are crucial in reducing the risk of transmission of HSV-2 to sexual partners.
E. Perineal care of genital lesions. Proper care of lesions can help reduce discomfort and prevent secondary infections.