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Questions 158

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Question 1 of 5

A 28-year-old client comes to the clinic for her first prenatal examination. In relating her obstetrical history, she tells the nurse that she has been pregnant twice before. She had a 'miscarriage' with the first pregnancy after 6 weeks. With the second pregnancy, she delivered twin girls at 31 weeks' gestation. One of the twins was stillborn and the other twin died at 4 days of age. Using a five-digit system, the nurse records her as being:

Correct Answer: C

Rationale: The first digit represents the total number of pregnancies. This client has been pregnant 3 times including this pregnancy. The twin pregnancy counts as only one pregnancy, and because she delivered prior to 37 weeks' gestation, the third digit is recorded as 1. The first digit represents the total number of pregnancies. This client has been pregnant 3 times including this pregnancy. The second digit represents the total number of full-term deliveries; she has lost two pregnancies before 37 weeks' gestation. At present, she has no living children, so the fifth digit is noted as 0. The client is pregnant for the third time, and the first digit reflects the total number of pregnancies. She has had no full-term deliveries, because she delivered prior to 37 gestational weeks, so the second digit is recorded as 0. The third digit represents the number of preterm deliveries, and a twin pregnancy counts as only one delivery. She lost an earlier pregnancy prior to 20 gestational weeks, and the fourth digit reflects spontaneous or elective abortions. Lastly, the fifth digit indicates the number of children currently living, and she has no living children. She is pregnant for the third time, and the first digit reflects the total number of pregnancies. In the previous two pregnancies, she delivered prior to 37 gestational weeks, thus having no full-term deliveries, which is indicated by the second digit. The fourth digit represents the total number of abortions, spontaneous or elective, and she reported a spontaneous abortion with her first pregnancy.

Question 2 of 5

MgSO4 is ordered IV following the established protocol for a client with severe PIH. The anticipated effects of this therapy are anticonvulsant and:

Correct Answer: B

Rationale: An anticonvulsant effect is the goal of drug therapy for PIH. However, we would not want to increase the vasoconstriction that is already present. This would make the symptoms more severe. An anticonvulsant effect and vasodilation are the desired outcomes when administering this drug. An anticonvulsant effect is the goal of drug therapy for PIH; however, hypertensive drugs would increase the blood pressure even more. An anticonvulsant effect is the goal of drug therapy for PIH. MgSO4 is not classified as an antiemetic. Antiemetics are not indicated for PIH treatment.

Question 3 of 5

The mother of a one-year-old wants to know when she should begin toilet-training her child. The nurse's response is based on the knowledge that sufficient sphincter control for toilet training is present by:

Correct Answer: B

Rationale: Sufficient sphincter control for toilet training typically develops between 18-24 months, when children gain the physical and cognitive ability to control urination and defecation.

Question 4 of 5

The nurse is providing dietary instructions for a client with iron-deficiency anemia. Which food is a poor source of iron?

Correct Answer: A

Rationale:
Tomatoes are a poor source of iron compared to legumes, dried fruits, and nuts, which are rich in iron.
Tomatoes provide vitamin C, which aids iron absorption, but lack significant iron content.

Question 5 of 5

The nurse is caring for a client with a chest tube. Which observation requires immediate intervention?

Correct Answer: D

Rationale: Lying on the affected side can compress the chest tube, obstructing drainage and risking pneumothorax or tension pneumothorax, requiring immediate repositioning. Continuous bubbling in the water seal is expected initially, and the other findings are appropriate.

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