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ECT ANSWERS (VERIFIED ANSWERS) LATEST2024/2025
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At 14- n
weeks gestation, a client arrives at the Emergency Center complaining of a dull pain i
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n the right lower quadrant of her abdomen. The nurse obtains a blood sample and initi
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ates an IV. Thirty minutes after admission, the client reports feelinga sharp abdominal
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pain and a shoulder pain. Assessment findings include diaphoresis, a heart rate of 12
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0 beats/minute, and a blood pressure of 86/48. Whichaction should the nurse implem
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ent next? n
a. Check the hematocrit results. n n n
b. Administer pain medication. n n
c. Increase the rate of IV fluids. n n n n n
d. Monitor client for contractions. - n n n n
n CORRECT ANSWER c. increase the rate ofIV fluids n n n n n n n n
A woman who thinks she could be pregnant calls her neighbor, a nurse, to ask wensh
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e could use a home pregnancy test to diagnose pregnancy. Which response is best?
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a. a home pregnancy test can be used right after your first missed period
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b. these tests are most accurate after you have missed your second period
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c. home pregnancy tests often give false positives and should not be trusted
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d. the test can provide accurate information when used right after ovulation -
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CORRECT ANSWER a. a home pregnancy test can be used right after your firstm
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issed period n
,A newborn, whose mother is HIV positive, is scheduled for follow-
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up assessments.The nurse knows that the most likely presenting symptom for a pedia
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tric client with AIDS is:
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a. shortness of breath n n
b. joint pain n
c. a persistent cold
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d. organmegaly - CORRECT ANSWER c. a persistent cold n n n n n n n
Twenty minutes after a continuous epidural anesthetic is administered, a laboringcl
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ient's blood pressure drops from 120/80 to 90/60. What action should the nursetake
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?
a. notify the healthcare provider or anesthesiologist
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b. continue to assess the blood pressure q5min n n n n n n
c. place the woman in a lateral position
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d. turn off continuous epidural -
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CORRECT ANSWER c. place the woman in alateral position
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In developing a teaching plan for expectant parents, the nurse plans to include inform
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ation about when the parents can expect the infant's fontanels to close. Thenurse base
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s the explanation on knowledge that for the normal newborn, the
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a. anterior fontanel closes at 2 to 4 months and the posterior by the end of the firstwe
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ek
b. anterior fontanel closes at 5 to 7 months and the posterior by the end of the week
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c. anterior fontanel closes at 8 to 11 months and the posterior by the end of these
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cond week n
d. anterior fontanel closes at 12 to 18 months and the posterior by the end of these
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cond month - n n
nCORRECT ANSWER d. anterior fontanel closes at 12 to 18 months and the pos
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terior by the end of the second month
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,A client in active labor is admitted with preeclampsia. Which assessment finding ism
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ost significant in planning this client's care?
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a. patellar reflex 4+ n n
b. blood pressure 158/80 n n
c. four hour urine output 240 ml
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d. respiration 12/minute - CORRECT ANSWER a. patellar reflex 4+
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A 4 week old premature infant has been receiving epoetin alfa for the last three weeks
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. Which assessment finding indicates to the nurse that the drug is effective?
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a. slowly increasing urine output over the last week
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b. respiratory rate changes from the 40s to the 60s n n n n n n n n
c. changes in apical heart rate from the 180 to the 140s
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d. change in indirect bilirubin from 12 mg/dl to 8 mg/dl - CORRECT ANSWER
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c. changes in apical rate from the 180s to the 140s
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A pregnant client tells the nurse that the first day of her last menstrual period wasAu
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gust 2, 2006. Based on Nagele's rule, what is the estimated date of delivery?
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a. April 25, 2007
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b. May 9, 2007
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c. May 29, 2007
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d. June 2, 2007 - CORRECT ANSWER b. May 9, 2007
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The nurse is performing a AGA on a full-
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term newborn during the first hour oftransition using the Dubowitz scale. Based
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on this assessment, the nurse determines that the neonate has a maturity rating of
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n40 weeks. Which findings should the nurse identify to determine if the neonate i
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s SGA? (Select all that apply.)
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a. admission weight of 4 lbs 15 oz n n n n n n
, b. head to heel length of 17 in n n n n n n
c. frontal occipital circumference of 12.5 in
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d. skin smooth with visible veins and abundant vernix
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e. anterior plantar crease and smooth heel surfaces
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f. full flexion of all extremities in resting supine position - CORRECT ANSWER
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a, b, c n n
The nurse assess a client admitted to the labor and delivery unit and obtains thefollo
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wing data: BP 110/68, FHR 110 bpm, cervix 1 cm dilated and uneffaced. Based on t
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hese assessment findings, what intervention should the nurse implement?
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a. insert a fetal monitor n n n
b. assess for cervical changes q1H n n n n
c. monitor bleeding from IV sites n n n n
d. perform Leopold's maneuvers - n n n
CORRECT ANSWER c. monitor for bleedingfrom IV sites
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Immediately after birth a newborn infant is suctioned, dried, and placed under aradia
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nt warmer. The infant has spontaneous respirations and the nurse assess anapical hear
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t rate of 80 bpm and respirations 20. What action should the nurse perform next?
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a. initiate positive pressure ventilation n n n
b. intervene after one minute APGAR is assessed n n n n n n
c. initiate CPR on the infant n n n n
d. assess the infant's blood glucose level -
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CORRECT ANSWER a. initiatepositive pressure ventilation
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A client with no prenatal care arrives at the labor unit screaming, "The baby is coming!
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" The nurse performs a vaginal examination that reveals the cervix is 3 cm
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