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Questions 158

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Question 1 of 5

A pregnant client experiences spontaneous rupture of membranes. The first nursing action is to:

Correct Answer: C

Rationale: Auscultating fetal heart rate is critical after membrane rupture to assess for cord prolapse, a potential complication.

Question 2 of 5

A client with a history of seizure disorder is admitted with complaints of breakthrough seizures. The nurse should give priority to:

Correct Answer: A

Rationale: Administering anticonvulsants is the priority to control breakthrough seizures and prevent status epilepticus.

Question 3 of 5

A client is admitted with suspected acute pancreatitis. Which lab finding confirms the diagnosis?

Correct Answer: D

Rationale: Elevated serum amylase (typically >3 times normal) is a key diagnostic marker for acute pancreatitis due to pancreatic enzyme leakage. The other findings are nonspecific or normal.

Question 4 of 5

A 17-year-old client has a T-4 spinal cord injury. At present, he is learning to catheterize himself. When he says, 'This is too much trouble. I would rather just have a Foley.' An appropriate response for the RN teaching him would be:

Correct Answer: A

Rationale: This response validates the client's feelings, provides education on reduced infection risk with intermittent catheterization, and encourages autonomy.

Question 5 of 5

What information should the nurse give a new mother regarding the introduction of solid foods for her infant?

Correct Answer: B

Rationale: Introducing solid foods one at a time with 4-7 day intervals allows identification of allergies. The extrusion reflex fades by 4-6 months, and mixing in bottles or starting with fruits is not recommended.

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