A nurse is caring for a client at the clinic.

Exhibits

Complete the following sentence by using the lists of options.

The client is at risk for
dropdown
as evidenced by
dropdown

Answer and Explanation

The Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"A"}

Rationale for correct choices

• Spontaneous abortion: The client is presenting at 10 weeks gestation with moderate, bright red vaginal bleeding and a history of risk factors including type 1 diabetes mellitus and recurrent infections. The open cervix on examination indicates that the pregnancy may not be viable and suggests impending or ongoing miscarriage.

• Cervical dilation: Cervical dilation is a key clinical sign of spontaneous abortion, as it indicates that the body is preparing to expel the pregnancy. The presence of an open cervix in conjunction with vaginal bleeding and cramping directly supports the risk for miscarriage. Monitoring cervical changes helps the healthcare team assess the progression and urgency of intervention.

Rationale for incorrect choices

• Molar pregnancy: Molar pregnancy typically presents with markedly elevated hCG levels, larger-than-expected uterine size, and absence of a viable embryo. Although the client has an elevated hCG, the level is not excessively high, and there is no indication of vesicular tissue or characteristic ultrasound findings, making molar pregnancy unlikely.

• Ectopic pregnancy: Ectopic pregnancy generally presents with unilateral abdominal pain, shoulder pain, and sometimes hypotension or signs of internal bleeding. The client’s bleeding is bright red, moderate, and accompanied by cervical dilation, which is not typical for an ectopic pregnancy. No abdominal mass or unilateral tenderness is reported, reducing the likelihood of this diagnosis.

• Lower abdominal cramping: While cramping is a symptom associated with miscarriage, it alone is not sufficient evidence to determine the risk for spontaneous abortion. Cervical dilation is a more definitive clinical sign indicating that the miscarriage may be occurring or imminent.

• hCG levels: The client’s hCG level of 30,000 IU/L is within the expected range for 10 weeks gestation and does not specifically indicate miscarriage. Unlike cervical dilation, hCG levels alone cannot confirm the risk for spontaneous abortion.

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Correct Answer is ["C","D","F"]

Explanation

Rationale:

A. Explain the cast application procedure to the child: Preparing the child for a future procedure is helpful but not immediately necessary. At this point, pain control and reduction of swelling take precedence to prevent complications and stabilize the injury.

B. Review cast care instructions with the child's parents: While parent education is important, it is secondary to immediate interventions that address pain, swelling, and preparation for the procedure. Priority actions focus first on the child’s current needs and safety.

C. Elevate the affected forearm with pillows: Elevation helps reduce edema and pain in the fractured extremity and prevents further swelling. This is a critical nursing intervention for acute fracture management before and after casting.

D. Apply ice packs to the fingers and along the right forearm: Ice helps manage pain and inflammation by vasoconstriction, limiting fluid accumulation in tissues. Applying it early post-injury is crucial to controlling swelling in a fractured limb.

E. Place a nonadherent dressing on the right knee abrasion: Caring for minor abrasions is important but is not a priority compared with interventions addressing fracture management, pain, and preparation for cast application.

F. Administer Ibuprofen 200 mg PO: Pain management is a priority in fracture care to maintain comfort and reduce distress. Administering analgesics before cast application helps the child tolerate the procedure and facilitates cooperation.

A. Instruct the client to carry the newborn in their arms when going to the nursery. B. Remove the electronic security sensor when the newborn is in the client's room. C. Apply identification bands after the newborn's first bath. D. Discourage family from posting photos of the newborn on social media.

Correct Answer is D

Explanation

Rationale:

A. Instruct the client to carry the newborn in their arms when going to the nursery: Carrying a newborn to the nursery without security measures increases the risk of abduction. Infants should always be transported in a secure bassinet or by authorized staff using the hospital’s safety protocols.

B. Remove the electronic security sensor when the newborn is in the client's room: The electronic security sensor is essential for monitoring the newborn’s location within the hospital. Removing it defeats the purpose of the abduction prevention system and is unsafe.

C. Apply identification bands after the newborn's first bath: Identification bands should be applied immediately after birth to ensure accurate identification from the start. Waiting until after the first bath delays verification and increases risk for misidentification or abduction.

D. Discourage family from posting photos of the newborn on social media: Sharing identifiable information or images online can inadvertently alert potential abductors to the newborn’s presence. Families should be advised to limit social media exposure until the infant’s safety can be ensured.

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A nurse is caring for a client at the clinic. Exhibits Complete the following sentence by using the lists of options. The client is at risk for dropdown as evidenced by dropdown

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is continuing to care for the child. Exhibits Select the 3 priority actions that the nurse should take.

Correct Answer is ["C","D","F"]

Explanation

A nurse is reviewing the safety plan for preventing newborn abduction with newly licensed nurses. Which of the following information should the nurse include in the teaching?

Correct Answer is D

Explanation

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A nurse is caring for a client at the clinic.

Exhibits

Complete the following sentence by using the lists of options.

The client is at risk for
dropdown
as evidenced by
dropdown