A nurse on an antepartum unit is reviewing the medical records for four clients. Which of the following clients should the nurse assess first?

A client who has placenta previa and a hematocrit of 36%.

A client who has hyperemesis gravidarum and a sodium level of 110 mEq/L.

A client who has diabetes mellitus and an HbA1c of 5.8%.

A client who has preeclampsia and a creatinine level of 1.1 mg/dL.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

A client with placenta previa and a hematocrit of 36% should be monitored closely due to the risk of bleeding, but it is not an immediate priority compared to the client with hyperemesis gravidarum and a low sodium level.

Choice B rationale:

Hyperemesis gravidarum is a severe form of morning sickness characterized by excessive vomiting, leading to dehydration and electrolyte imbalances. A sodium level of 110 mEq/L is dangerously low and requires immediate attention to correct the electrolyte disturbance and prevent further complications.

Choice C rationale:

A client with diabetes mellitus and an HbA1c of 5.8% is within a normal range, indicating good glycemic control. This client's condition can be managed on an outpatient basis and does not require urgent assessment compared to the others.

Choice D rationale:

A client with preeclampsia and a creatinine level of 1.1 mg/dL should be closely monitored, but it is not the priority over the client with hyperemesis gravidarum and severe electrolyte imbalance.

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Correct Answer is C

Explanation

Choice A rationale:
Preterm gestational age is not indicated by the presence of breast tissue with a flat areola and no bud. Preterm newborns may have immature breast tissue, but it does not manifest as a flat areola with no bud.

Choice B rationale:
Decreased maternal hormones during pregnancy would result in less developed breast tissue in the newborn, but it wouldn't present as a flat areola with no bud. Instead, the breast tissue may be small and less pronounced.

Choice C rationale:
Congenital anomaly refers to a birth defect or malformation that occurs during fetal development. In this case, the flat areola with no bud suggests an abnormality in the development of the breast tissue. Further assessment and evaluation may be required to determine the exact nature of the anomaly.

Choice D rationale:
Ambiguous secondary sex characteristics would involve the presence of characteristics that are not clearly male or female. The described breast tissue does not fit this category, as it is specifically described as having a flat areola with no bud, which is more indicative of a congenital anomaly.
Question 65.

A. Measure the abdominal circumference at the level of the newborn's umbilicus every 12 hr. B. Insert an orogastric decompression tube with low wall suction. C. Provide the newborn with an iron-rich formula containing vitamin B12 every 2 hr. D. Administer nitric oxide inhalation therapy to the newborn.

Correct Answer is A

Explanation

Choice A rationale:

Measuring the abdominal circumference at the level of the newborn's umbilicus every 12 hr is a critical action in this scenario. The newborn has necrotizing enterocolitis (NEC), a serious gastrointestinal condition, and measuring abdominal circumference can help monitor for changes in abdominal distention, which is a sign of NEC progression.

Choice B rationale:

Inserting an orogastric decompression tube with low wall suction may not be the most appropriate action for a newborn with NEC. While decompression tubes can be used in some cases of NEC, their insertion should be guided by specific clinical indications, and not all cases require them.

Choice C rationale:

Providing the newborn with an iron-rich formula containing vitamin B12 every 2 hr is not indicated for NEC. NEC requires specialized medical management and treatment, which may include bowel rest and other interventions, but providing iron-rich formula is not one of them.

Choice D rationale:

Administering nitric oxide inhalation therapy is not relevant to the management of NEC. Nitric oxide inhalation therapy is used for respiratory conditions, particularly persistent pulmonary hypertension of the newborn, and does not address the gastrointestinal issues seen in NEC.

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A nurse on an antepartum unit is reviewing the medical records for four clients. Which of the following clients should the nurse assess first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is performing an assessment for a newborn and notes breast tissue that has a flat areola with no bud. The nurse should identify that this finding indicates which of the following conditions?

Correct Answer is C

Explanation

Exhibits A nurse is caring for a 2-day-old newborn who was born at 35 weeks of gestation. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

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A nurse is caring for a client who has developed eclampsia. Which of the following actions should the nurse implement after the client experiences a convulsion?

A nurse is performing a nonstress test on a client who is at 35 weeks of gestation and has diabetes mellitus. The test reveals no accelerations of fetal heart rate for 20 min. Which of the following actions should the nurse take?