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NEW QUESTION 53
A gravida 2 para 1 client delivered a full-term newborn 12 hours ago. The nurse finds her uterus to be boggy, high, and deviated to the right. The most appropriate nursing action is to:
- A. Have the client void and then re-evaluate the fundus
- B. Notify the physician
- C. Place the client on a pad count
- D. Massage the uterus and re-evaluate in 30 minutes
Answer: A
Explanation:
Explanation
(A) The nurse should initiate actions to remove the most frequent cause of uterine displacement, which involves emptying the bladder. Notifying the physician is an inappropriate nursing action. (B) The pad count gives an estimate of blood loss, which is likely to increase with a boggy uterus; but this action does not remove the most frequent cause of uterine displacement, which is a full bladder. (C) Massage may firm the uterus temporarily, but if a full bladder is not emptied, the uterus will remain displaced and is likely to relax again.
(D) The most common cause of uterine displacement is a full bladder.
NEW QUESTION 54
A client is receiving IV morphine 2 days after colorectal surgery. Which of the following observations indicate that he may be becoming drug dependent?
- A. He is euphoric for about an hour after each injection.
- B. He asks for pain medication although his blood pressure and pulse rate are normal.
- C. He is asleep 30 minutes after receiving the IV morphine.
- D. The client requests pain medicine every 4 hours.
Answer: A
Explanation:
Explanation/Reference:
Explanation:
(A) Frequent requests for pain medication do not necessarily indicate drug dependence after complex surgeries such as colorectal surgery. (B) Sleeping after receiving IV morphine is not an unexpected effect because the pain is relieved. (C) A person may be in pain even with normal vital signs. (D) A subtle sign of drug dependency is the tendency for the person to appear more euphoric than relieved of pain.
NEW QUESTION 55
What specific hormone must be present in serum or urine laboratory tests used to diagnose pregnancy?
- A. -fetoprotein
- B. Human chorionic gonadotropin
- C. Estrogen
- D. Sphingomyelin
Answer: B
Explanation:
(A) Human chorionic gonadotropin is the biochemical basis for pregnancy tests. It is produced by the placenta to help maintain the corpus luteum. Its levels climb rapidly following conception, peaking at about 8 weeks and then gradually decreasing to low levels after 16 weeks. (B) Estrogen does steadily rise throughout pregnancy, increasing to 30 times that of prepregnancy levels. Although estrogen levels do change during pregnancy, it is not used as the main hormone of evaluation in pregnancy tests. (C) -Fetoprotein is the major protein in the serum of theembryo. It is initially produced by the yolk sac. (D) Lecithin and sphingomyelin are two phospholipids of which fetal lung surfactant is composed. Levels are evaluated to determine fetal lung maturity.
NEW QUESTION 56
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