問題一覧
1
Nurse micah is assigned to the ER. She is currently attending to a client with a complaint of acute abdominal pain. Which of the following actions of nurse micah demonstrates respect of clients autonomy?
c. Facilitating and supporting clients's choices regarding treatment options
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2. The nurse obtain the BP of the client and have a reading of 160/100. The nurse did not tell the client the reading because she believes that this information will upset him and consequently further elevate his BP. This situation illustrates an example of:
D. Beneficence
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3. Which of the following statements is true regarding informed consent?
C. It is ethical or legal for nurses to obtain informed consent for procedure that are to be performed by the physician
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4. The nurse compassion is aroused when the patient under her care is suffering and is in a prolonged life - sustaining machine. Many times the nurse experiences feeling of uneasiness and anguish. This human condition that confronts the nurse gives rise to:
B. Ethical dilemma
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5. The nurse shows respect to human dignity when she observes which of the follwing situations when caring for the clients?
D. Planning nursing care together with the client and immediate relative
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6. A hypertensive client is ordered to receive 20 mEq of Potassium chloride. The bottle is labeled KCL elixir 10 mEq/ml. How many ml should be given?
B. 2 ml
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7. A client who is experiencing tachycardia is ordered to receive Digoxin 0.325 mg OD. The stock is 0.25 mg/tab. How many tab should be given to the client?
A. 1.5 tab
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8. A client who have episodes of seizure is orderedto received Dilantin 5mg/kg body weight is ordered to a client who weighs 50lbs. The drug is to be administered in 3 equal doses. The label reads Dilantin suspension 125 mg/ml. How much medication should be administered to the client?
B. 1.0 ml
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9. A post exploratory laparotomy client has an order for meperidine hydrochloride 50mg every 4 hrs PRN. The multiple vialdose is labeled 50 mg/ml. What is the correct dose to be admin#istered to this client when he complains of pain?
D. 1.0 ml
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10. An order is given to a young adult to receive 1 million units of penicillin. The stock on hand is Penicillin 500,00 units and the direction reads: add 1.3ml to yield 2ml. What is the correct amount to be administered
D.4 ml
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11. Which of the follwing are the benefits of comiung up with a strategic plan?
D. All of the options
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12. The team started the plannign session with an aim to revisit the institution's vision-mission. Vision pertains to:
B. Preferred future of the organization
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13. In the strength, weakness,opportunities and threats analysis, theorganizational straucture os the medical coenter inclding the chain of command were analyzed. Which of the floowing describes an authoritative type of org
Control and communication flow is from top down
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14. The team were unanimous in saying that the medical canter is a people oriented organization which promotes empowerement.When tehre is a decentralization of power it promotes the following except?
Promotes long range planning than short term planning
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15. he outcome ofthe strategic plan session by the representative groups is for the medical center to have a shared governance. It means:
All of the options
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16. A research idea or problem is generated through the following except:
Recommendation for funding source
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17. Your team is interested to consider handwashing as a topic for research. The statement, "in what situations do staff nurses wash their hands in the dlinical areas?" This is an example of a research.
Problem
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In the final selection of a research problem, aside from its significance to nursing practice, you will also have to consider the following criteria, except:
Investigators work schedule
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19, You know that a good research problem should exhibit the following characteristics, Which one is NOT always included?
Indicates the hypothesis to be tested
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20. You also know that a good research requires a thorough review of the literature. The first step in searching for literature to locate all pertinent sources is to
identify key words and concepts to be searched
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21. The following statements are true in spiritual care nursing except:
Referral or utilize members of the team is not important for spiritual care as it is for other aspects of care
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22. The fallowing are vulnerable groups needing spiritual spiritual care:
All are corect
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23. The following statements are true of Parish nursing also known as faith community nurse:
All are correct
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24. Roles of a parish nurse includes all of the following
All are true except 6
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25. The following statement are true of palliative/ hospice care
All are corect
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26. Andrea s immediately transferred to the D R tble. Which of the following conditions signify that delivery is near?
12,3
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27. Artificial rupture of the membrane is done. Which of the following nursing diagnoses is the priority?
Potential for injury related to prolapse cord
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28. Yannie complains of severe abdominal pain and back pain during contraction. Which two of the following measures will be MOST effective in reducing pain?
1,2
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29. Lumbar epidural anesthesia is administered. Which of the following nursing responsibilities should be done immediately following procedure?
Assess for maternal hypotension
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30. The nurse is caring for a woman in labor. The woman is irritable, complains of nausea and vomits and has heavier show. The membranes upture. The nurse understands that this indicates:
The woman is in transition stage of labor
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31. A school-age child needs 5 units of regular insulin to be administered. She is in the playroom when you are ready to give the injection. Your best action would be to:
Tell her to come oautside he playroom for the injection.
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32. Diabetes insipidus (DI) is suspected ina child. HS parents asked Nurse Mak how often the child needs insulin
"Your child's condition does not necessarly need insulin regimens."
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33. A patient with Cushing's syndrome due to a primary tumor is expected to have elevated levels of the following, except:
Antidiuretic hormone
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34: Isabella is suspected to have diabetes mellitus (DM). Her first test reveals elevated blood sugar. She was required to undergo a second test of her blood sugar. Which of these results woud confirm presence of DM?
Fasting blood sugar 130 mg/dL
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35. Which toy would you expect to provide the best therapeutic play for a-child . who has to receive daily medicine injections?
Syringe to practice injections
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36. Ian is a pediatric pabient of Nurse Regine. Ian is diagnosed with Duchenne's Muscular Dystrophy (DMD). Because of this condition, when lan tries to walk, he is said to walk up his thighs. front" Regine notes pressing sign his as:
Gower's sign
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37. To maintain the optimal functioning of lan's muscles, select the interventions that Nurse Regine should include in her care plan and discharge plan.
i, iii, iv, v
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38. Nurse Regine is handling another patient vith myelomeningocele, a type of spina bifida. Nurse Regine knows that neural tube disorders like spina bifida is prevented by prenatal intake of which of the following?
Vitamin B9
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39. The patient with myelomeningocele s placed under a wammer without any clothing. How should Nurse Regine care for the patient's sac?
Apply sterile, moist, nonadherent dressing over the sac
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40. In feeding the infant with the myelomeningocele sac, how should Nurse Regine position him to prevent complications?
Keep the patient in prone position with the head tmed to the side.
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41. In one of the studies conducted, the hypothesis formulated nurses was stated, "Baccalaureate degree-prepared practice more palliative nursing measures on a client in an ICU than will associate degree-prepared nurses. " The independent variable here is:
Type of educational background of nurses
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42. In a certain study, the researcher was asked to include the subjects' gender, Gender is classified in what scale of measurement?
Nominal
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43. Empiridism refers to:
Gathering evidence rooted in objective reality
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44. In conducting a research, you did not collect any information that would link to the identification of the participants to their responses. The ethical guideline obserbed is:
Anonymity of respondents
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45. As you write your introduction for your study, you must take all of the following considerations, except:
Presenting every detail of the study concisely
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46. Which of the following food products should be eliminated in the diet of a child with Phenylketonuria?
milk
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47. In clients vith Phenyiketonuria, at which developmental period would the dietary restrictions be easily applied?
Infancy
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48. Which of the following is recommended for newboms and infants who are diagnosed with Galactosemia?
soy-based formula
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49. For newboms diagnosed with Maple Syrup Urine Disease, which of the following vitamins should be increased in their diet?
Vitamin K
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50.All of the following can trigger hemotysis in children with Glucose-6-Phoshate-Dehydrogenase Defidency, except:
junk food
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51. A 13 year old female with structural scoliosis has Harrington rods inserted, Nurse Sunshine knows that the best position during the post- operative period is:
supine in bed
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52. Which of the fallwing observations does Nurse Sunshine expect to see in her patient with thoracic scoliosis?
The patient's thoracic area is asymmetrical
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53. A child with bilateral dubfeet is going home with corrective braces after having both casts removed. Nurse Sunshine is completing discharge teaching for the parents. Which of the following is the highest priority?
Increase the time of interval of wearing the braces and have the child wear them eventually as much as possible
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54: Which of the following positions of the femur is accurate in relation to the acetabulum in a child with congenital hip dislocation?
superior
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55. Nurse Sunshine knows that structural scoliosis is not:
A compensatory mechanism in children who have unequal leg lengths and refractive errors
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56. Nurse Ivee inquires about the activity level of a 3-year-old under her care. The mother states that the child loves to play at the park, and the nurse encourages the mother to continue physical activities. What important principle guides the nurse's response?
allowing the toddler to walk, run and hop enhances the child's kinesthesia
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57. The father of a 2/2 year old asked nurse Ivee how to prevent earty childhood dental cavities. The best response by nurse Ivee would be:
"Make sure your child's diet is nutritious, and limit
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58. Iin caring for a 3-year-old, Nurse Iivee knows that she needs to obtain the height of the child as part of routine heaith screening. To obtain an accurate measurement, the child must:
remove his shoes and stand upright, with head level
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59, The mother of a 3-vear old child also under Nurse Ivee's care tells her that the child has frequent nightmares. The Statement by the mather that indicates the need for more teaching iS:
"I take her to my bed so she will calm down."
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60. Our school curricula now include educating the young regarding human sexuality. What is the most appropriate age group for the nurse to incorporate these in her instructions?
11 years old
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61. Which of the following is not true about hydrocephalus. It is
a. A disorder that occurs only at birth
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62. Magnetic resonance imaging is done, Which of the following results does not confirm the diagnosis of hydrocephalus?
atrophied brain
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63. The top priority in rendering nursing care to this patient is:
Monitor signs of increased intracranial pressure
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64. At nine months old, which of the fallowing behaviors Is indicative that his development is delayed. He can:
Sit with support
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65. Kenneth underwent ventriculo-peritoneal shunting. What is the best position for Kenneth post-operatively?
Flat on bed
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66. The nurse is preparing a woman for epidural anesthesia. The woman asks why is my IV running so fast? It feels so cold" what is the appropriate reply of the nurse?
"IV hydration helps prevent the blood pressure from dropping so low"
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67. A woman arrived to the labor suite and states I have water leaking down my legs'" What assessment is most appropriate in this situation?
Fern test
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68. it is most likely that the physician would consider perforing an amnioinfusion when external fetal monitor tracing Shows:
Deep variable decelerations with every contraction
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69. A woman carrying a breeched fetus is scheduled for external version. She says to the nurse "T'm realy scared of the procedure, will it hurt badly?" What is the best reply of the nurse?
"Sometimes the procedure is uncomfortable. If it becomes too painful, ket the doctor know and she will stop the procedure.
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70. Which statement by a postpartum woman after caesarean delivery indicates that further discharge teaching is needed?
Being tired may increase the pain I feel."
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71. Socorro is aware that in accordance with R.A. 7600 of 1992, the purpose of the "rooming- in" national policy are two-fold;
1, 3 are correct
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72, Soon after both mother and baby were settied in their hospital room, the pediatrician, who'is now in the hospital. came to see the baby. After reviewing the baby's condition immedlately after dellvery, she asks, "Is there a standard milk formula the hospital prescribes or would want us to use?" Nurse Melody was quick to respond , "'I am somry, but shouldn't we be adhering to the National Milk Code Act of 2006 and the Expanded Breasteeding Act of 2009?" This reflects the nurse's role as:
patient-advocate and law-abiding practicing health worker
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73. Socorro is very much aware that in the case of the newbomn, within the first hour after birth, that which is necessary?
Immediate initiation of breastfeeding continued within 6 months up to 2 years and beyond without complementary milk formula. Complementary feeding started only at 6 months.
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74. After her duty hours, a milk company representative approached Socorro offering her part time job with them. Socorro tumed down the offer because this is in conflict with her desire to promote breastfeeding. In addition, Section 32 of Administrative Order 2006-0012 as implementing rules and regulations to Executive Order No. 51 (Milk Code Policy):
provides that it is the primary responsibility of the health workers to promote, protect, and support breasreedings and appropriate infant and young child feeding and that no assistance, logistics, Or training from milk company is permitted
75
75. Socorro attended a meeting in the hospital representing her ward, where she pushed for adherence to the Expanded Breastfeeding Promotion Act of 2009"RA 7600 (Rooming-In and Breastfeeding Act). This measure provides the 3" vital component of the breastfeeding law (PROVISION OF SUPPORT for the practice of breastfeeding) by:
mandating the provision of facilities for breastmilk colledtion and storage (e.g.milk banks) and establishment of "lactation stations" with adequate
76
Situation: The nurse Is caring for a G3P1 postpartum dient who just had her delivery. 76. The nurse is checking for the patients VS and noticed that her temperature is increased. The mother noticed that she also feels really warm and thirsty. What would the nurse tell the patient?
Tell the patient that what she is experlencing Is normal within 24 hours.
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77. After 3 days, the patient, had a urinalysis. The nurse noticed that the patient's BUN is relatively high. What would the nurse do?
Note the occurrence as nomal.
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78. Knowing that the patient has high levels of BUN in her urine. What would the nurse tell the client about her diet?
Tel the client to increase her intake of CHON-rich food.
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79. The patient is about to be discharged from the clinic, The patient asks the nurse of when her menses will return if she will not continuously breastfeed her baby. What wil be the proper health teaching of the nurse?
The patient will have her menstrual flow back on track in 6-10 weeks after giving birth.
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80. The client after she was discharged came back to the clinic in her 3rd postpartum day. She noticed that her breasts are really full and that she feels that it's really tense. What will the nurse tell the patient?
Tell the client that the breasts become tender and full at the start of the 34 postpartum day.
81
Situation: Marie Amoure calls her pre-natal clinic to report that, she had intermittent ower abdominal cramping and occasional spotting for the last 24 hrs. Her last menstrual period was eight weeks ago. Two weeks agos she had a positive pregnancy test. 81. The most likely diagnosis for Dollies condition on the basis of the information presented is:
threatened abortion
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82. Marie Amoure comes to clinic. Pelvic examination reveals vaginal bleeding but no dilation of the cervix, confirms the tentaive diagnosis.Which of the following shoulf not be considered in the management of Kate's disorder?
Administering of diethyistilibestrol (Synthetic estrogen)
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83. A week later Marie Amoure comes back to the emergency room because of heavy bleeding and severe cramps. Vaginal examinations reveals that her cervix is dilated and tissue is bulging through the os. Which of the fallowing would be the best procedure in managing this new condition?
oytocin stimulation
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84. Which of the fallowing positions shouid the nurse place the patient who has been diagnosed with a prolapsed cord
Trendelenberg
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85. A woman has been in preterm labor off and on for 2 weeks. She is 28 weeks pregnant. It seems inevitable that she will delivery soon, Which of the fallowing medications would the nurse prepare to give this patiert?
celestone
86
Stuation: As a newly registered nurse, Nurse Nenita was emplayed in a government hospital and is assigned in the matemnity unit, Here, she takes care of gravidomorbid clients. It is essential to know the normal and abnormal changes in pregnancy in order to deliver the best nursing care. The following questions apply. 86. During the night shift, a woman is hospitalized for the treatment of severe preeclampsia. Which of the following represents an unusual fîinding for this condition?
Convulsions.
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87. As a nurse in the maternity unit, Janine knows that the action of hormones during pregnancy affect the body by?
Raising resistance to insulin.
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88. A 28-year-old woman has had diabetes mellitus since she was an adolescent. She is 8 weeks pregnant and is admitted under the care of Nurse Nenita. Hyperglycemia during her first trimester will have what effect on the fetus?
Malformed organs.
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89. Nenita is caring for a young diabetic woman who is in her first trimester of pregnancy. As the pregnancy conuinues the nurse should anticipate which change in her medication needs?
The variable pattem of Insulin absorption throughout the pregnancy requires constant close adjustment.
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90. Methylergonovine (Methergine) is prescribed for a client with postpartum hemorrhage, Before Nenita administers the medication, she contacts the health care provider who prescribed the medication if which condition IS documented in the client's medical history?
Peripheral vascular disease
91
STtuation; Nurse Rancelle is addressing concemns of several dients in the out-patient department of a lying-in clinic. The following clients consulted Nurse Rancelle, thus, she performed health teachings. 91. During a visit to the prenatal clinic, Mia is at 32 weeks' gestation and complains of heartburn. After Rancelle's heath teaching, the client needs further instruction when Jenny says she must do what?
Consume liquids only between meals.
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92. Rancelle is teaching a new prenatal client about her iron deficiency anemia during pregnancy. Which statemnent indicates that the client needs further instruction about her anemia?
" I may have anemia because my family is of Aslan descent."
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93. An antenatal primagravid client has just been informed that she is carrying twins. The plan of care includes educating the client concerning factors that put her at risk for problems during the pregnancy. Nurse Rancelle realizes. the client needs further instruction when she Indicates carrying twins puts her at risk for which of the folowing?
Group B Streptococcus.
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94. A 30-year-old multigravid client has missed three periods and now visits the prenatal clinic because she assumes she is pregnant. She is experiencing enlargement of her abdomen, a positive pregnancy test, and changes in the pigmentation on her face and abdomen. These assessment findings reflect this woman is experiencing a cluster of which signs of pregnancy?
probable.
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95. An antenatal client receives education concerning evaluates that are safe to USe during pregnancy. medications the Client's understanding of the Rancelle instructions and determines that she needs further information when she states which of the following?
"If I need to have a bowel movement, Ex-Laxis preferred."
96
Situation: Nurse Coachie is a community health nurse and has paid particular attention to Rhufa, a 16 year old client at 30 weeks gestation. 96. Nurse Coachie is developing a teaching plan for a dlient entering the third trimester of her pregnancy, He should include all of the following in the plan, except:
Ambivalence concerning pregnancy.
97
97." Rhufa, who ls being monitored at home with home nursing visitss, diagnosed with mild preeclampsia and has gained 2 lb in the past week Her current blood pressure is 144/92 mm Hg. Which assesment finding would require further action by the Nurse Coachie?
Occasional headache.
98
98, At 32 weeks gestation, Rhufa, a 15y/o primigravid client who is 5 feet, 2 inches tall has gained a total of 20 lb, with a 1-lb gain in the last 2 weeks. Urinalysis reveals negative glucose and a trace of protein. The nurse should advise the dient that which of the following factors increases her risk for preeclampsia?
Adolescent age group.
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99. After instructing Rhufa, who is now at 38 weeks' gestation, about how preeclampsia can affect the client and the growing fetus, nurse Coachie realizes that the client needs additional instruction when she says that preeclampsia can lead to which of the following?
Hydrocephalic infant.
100
100. Pat was rushed to the hospital and is experiencing pain during the first stage of labor. The nurse on duty should instruct her to do all of the following, except:
Sip ice water.