Rationale for correct choices

• Hydatidiform mole: The client’s findings are consistent with a molar pregnancy. Key indicators include an intrauterine mass with cystic vesicles on ultrasound, absence of a fetus, elevated fundal height (28 cm at approximately 4 months gestation), and symptoms such as nausea/vomiting and dark brown vaginal discharge. Elevated blood pressure and anemia further support this diagnosis due to trophoblastic disease.
• Prepare the client for suction curettage: Suction curettage (D&C) is the primary treatment to evacuate abnormal trophoblastic tissue from the uterus. It helps prevent complications such as hemorrhage and progression to gestational trophoblastic neoplasia.
• Discuss weekly pregnancy hormone level monitoring: Serial monitoring of human chorionic gonadotropin (hCG) levels is essential to ensure complete resolution of trophoblastic tissue and to detect persistent disease or malignancy early.
• Vaginal bleeding: Bleeding is a common complication due to abnormal placental tissue and uterine evacuation. Monitoring helps detect hemorrhage or retained products.
• Blood pressure: Hypertension can occur with molar pregnancy due to excessive hCG levels and trophoblastic proliferation; monitoring helps detect complications such as preeclampsia-like symptoms.

Rationale for incorrect choices

• Ectopic pregnancy: This typically presents with unilateral pelvic pain and absence of intrauterine pregnancy on ultrasound, not a uterine mass with cystic vesicles.
• Abruptio placentae: Would present with painful vaginal bleeding and a tender, rigid uterus in later pregnancy, not cystic vesicles or absent fetus.
• Placenta previa: Characterized by painless bright red bleeding and a low-lying placenta, not uterine mass or elevated fundal height discrepancies.
• Prepare the client for an emergency cesarean birth: There is no viable fetus present, and ultrasound confirms absence of fetal structures.
• Administer terbutaline: Used for uterine relaxation in preterm labor, which is not applicable here.
• Cervical dilation: Not a key indicator in molar pregnancy; cervix is not the primary focus of pathology.
• Uterus for hypertonicity: Not typical; the uterus may be enlarged but not characteristically hypertonic.
• Unilateral pelvic pain: More consistent with ectopic pregnancy, not molar pregnancy.

A. The anterior fontanel typically remains open until about 12 to 18 months of age, sometimes even up to 24 months. Therefore, in an 8-month-old infant, it is expected and normal for the anterior fontanel to still be open, soft, and flat.

B. The posterior fontanel normally closes much earlier, usually by 6 to 8 weeks of age (around 2 months). At 8 months, it should already be closed. If it remains open, it may indicate conditions such as hypothyroidism or increased intracranial pressure, and would require further evaluation.

C. The anterior fontanel is significantly larger than the posterior fontanel. The posterior fontanel is small and triangular, while the anterior fontanel is larger and diamond-shaped. Therefore, they are not expected to be the same size at any age.

D. Molding refers to the temporary shaping of the infant’s head during vaginal delivery due to overlapping of skull bones. This condition typically resolves within a few days after birth. At 8 months, molding should no longer be present, so this would be an abnormal finding.

A. A pain level of 4/10 is considered mild to moderate pain and is expected in the early postoperative period following a total abdominal hysterectomy. This level of pain can typically be managed with prescribed analgesics and does not require immediate provider notification.

B. A small (scant) amount of dark red drainage is expected within the first several hours after surgery due to residual bleeding at the surgical site. As long as the drainage is not increasing, bright red, or excessive, it is considered a normal postoperative finding.

C. Decreased or absent bowel sounds are expected in the early postoperative period due to the effects of anesthesia and bowel manipulation during surgery. This condition, known as postoperative ileus, is common and usually resolves gradually.

D. Urinary output should be at least 30 mL/hr in an adult. Over 3 hours, the expected minimum output is 90 mL. An output of 75 mL (25 mL/hr) indicates oliguria, which may suggest hypovolemia, decreased renal perfusion, or possible complications such as hemorrhage. This finding requires prompt reporting to the provider for further evaluation and intervention.

• Apply warm compresses to eyes (Unanticipated): This intervention has no role in managing a pituitary adenoma or increased intracranial pressure (ICP). Eye compresses may be used for localized ocular conditions (e.g., stye, conjunctivitis), not neurological or intracranial pathology.
• Implement seizure precautions (Anticipated): A pituitary adenoma with neurologic symptoms (confusion, restlessness, headache, vomiting) suggests possible increased ICP or brain irritation. These conditions increase seizure risk, so seizure precautions (padding side rails, suction setup, airway protection) are appropriate.
• Administer furosemide (Anticipated): Furosemide is a loop diuretic that can help reduce intracranial pressure by decreasing cerebral edema and fluid volume. It is appropriate in suspected ICP elevation.
• Administer 0.9% sodium chloride 1000 mL IV at 150 mL/hr (Unanticipated): Large-volume isotonic fluid administration may worsen cerebral edema and increase ICP. In patients with suspected elevated ICP, fluid management must be cautious to avoid exacerbation of brain swelling.
• Administer dexamethasone (Anticipated): Dexamethasone is a corticosteroid that reduces cerebral edema and is commonly used in pituitary tumors or brain masses to decrease inflammation and ICP-related symptoms.

A. Omeprazole is a proton pump inhibitor used to reduce gastric acid production and prevent ulcers. It does not impair wound healing and is commonly used perioperatively to protect the gastrointestinal tract, especially in clients taking NSAIDs or steroids.

B. Digoxin is a cardiac glycoside used to improve heart contractility and manage conditions such as heart failure or atrial fibrillation. It does not affect tissue repair or wound healing.

C. Morphine is an opioid analgesic used for pain control. While it can cause side effects such as respiratory depression, constipation, and sedation, it does not directly delay wound healing.

D. Prednisone is a corticosteroid that suppresses the immune system and inhibits the inflammatory response, which is essential for normal wound healing. It can decrease collagen synthesis, impair tissue regeneration, and increase the risk of infection. Clients taking corticosteroids, especially those with chronic conditions like rheumatoid arthritis, are therefore at increased risk for delayed wound healing, particularly after surgery.

A. Hydrochlorothiazide is a thiazide diuretic commonly prescribed for hypertension and edema. The dose of 12.5 mg twice daily is within an acceptable range. Although diuretics are often given in the morning to prevent nocturia, this order is clear and complete, so no clarification is required.

B. Zolpidem is a sedative-hypnotic used for insomnia. The prescription clearly states the dose, route, and timing (at bedtime). This is a standard and complete order.

C. This is a nasal corticosteroid used for allergic rhinitis. The prescription includes the medication, dose, route (intranasal), frequency, and specific instructions, making it clear and appropriate.

D. The nurse should clarify this prescription because the dose is written as “.5 mg” without a leading zero. According to safe medication administration practices, a leading zero (0.5 mg) must be used to prevent dosing errors. Without it, the dose could be misread as 5 mg, which could result in overdose. This violates safety standards and requires clarification before administration.

A. Acute poststreptococcal glomerulonephritis (APSGN) occurs as a delayed immune response to infection with group A beta-hemolytic streptococcus, commonly following skin infections (impetigo) or pharyngitis. Children between 5 and 12 years old are at highest risk. Therefore, a child recovering from impetigo is at significant risk for developing APSGN.

B. Appendicitis is typically caused by obstruction and bacterial infection of the appendix, not by streptococcal infection. It is not associated with poststreptococcal complications such as glomerulonephritis.

C. Pyloric stenosis is a condition involving hypertrophy of the pyloric muscle, leading to gastric outlet obstruction. It is not related to streptococcal infections and does not increase the risk for APSGN. Additionally, APSGN is rare in infants this young.

D. Pregnancy itself does not increase the risk of developing APSGN. The condition is specifically linked to recent streptococcal infections, which are not indicated in this scenario.

A. This is correct and one of the most important safety interventions. Keeping the head of the bed elevated to at least 30–45° helps prevent aspiration of gastric contents into the lungs. Clients receiving continuous enteral feedings are at increased risk for aspiration, especially if they have decreased level of consciousness or impaired swallowing. Maintaining this position reduces the risk of aspiration pneumonia and should be continued during feeding and for a period afterward if feedings are intermittent.

B. Enteral feeding formulas provide an ideal environment for bacterial growth. Changing the feeding container and tubing every 24 hours helps reduce the risk of contamination and infection. Failure to do so can increase the likelihood of gastrointestinal infections and compromise client safety.

C. Enteral formula should be administered at room temperature. Cold formula can cause abdominal discomfort, cramping, and decreased tolerance. It may also slow gastric emptying, leading to increased residuals and risk of complications.

D. X-ray is the most accurate method for verifying feeding tube placement, but it is only used at the time of initial placement. Daily x-rays are not appropriate due to unnecessary radiation exposure and impracticality. Ongoing verification is done by assessing aspirate pH, checking the length of the tube, and monitoring for signs of displacement.

E. Monitoring gastric residual volumes every 4 hours helps assess how well the client is tolerating the feeding. Elevated residuals may indicate delayed gastric emptying and increase the risk of aspiration. Identifying this early allows the nurse to intervene appropriately, such as holding the feeding and notifying the provider.

Rationale for correct choices

• Dry mouth (HEENT): Amitriptyline blocks muscarinic (acetylcholine) receptors, leading to decreased salivary gland secretion. This results in xerostomia (dry mouth), which can increase risk for dental caries, oral infections, and difficulty swallowing. Patients should be taught to increase fluid intake, chew sugarless gum, or use saliva substitutes.
• Tachycardia (Cardiovascular): TCAs inhibit norepinephrine reuptake and also have anticholinergic effects, both of which can increase heart rate. Additionally, TCAs can affect cardiac conduction (prolonged PR, QRS, QT intervals), making tachycardia and dysrhythmias important adverse effects to monitor, especially in older adults or those with cardiac disease.
• Urinary retention (Genitourinary): Anticholinergic effects reduce detrusor muscle contraction in the bladder, making it difficult to initiate urination and fully empty the bladder. This can lead to bladder distention and discomfort, particularly in older adults or those with prostate enlargement.
• Constipation (Gastrointestinal): TCAs decrease gastrointestinal motility due to their anticholinergic properties. This slows peristalsis, leading to constipation. Patients should be encouraged to increase fiber intake, fluid intake, and physical activity to prevent complications like fecal impaction.

Rationale for incorrect choices:

• Double vision: Although TCAs can cause blurred vision due to anticholinergic effects, dry mouth is a more common and expected finding emphasized in teaching.
• Sore throat: Not associated with TCA use; may indicate infection rather than medication effect.
• Chest pain: Not a typical expected side effect; could indicate a serious cardiac issue and requires immediate evaluation.
• Hypertension: TCAs are more likely to cause orthostatic hypotension due to alpha-1 blockade, not hypertension.
• Hematuria: No mechanism linking TCAs to blood in urine.
• Urinary incontinence: Opposite of expected effect; TCAs cause retention, not leakage.
• Weight loss: TCAs often cause weight gain due to increased appetite and metabolic effects.
• Diarrhea: Due to decreased GI motility, constipation—not diarrhea—is expected.

A. The ventrogluteal site is the preferred site for intramuscular (IM) injections in adults. It is well-developed, has a large muscle mass, and is free of major nerves and blood vessels, making it the safest and most reliable site. It also allows for better absorption of medication and reduces the risk of complications such as nerve injury.

B. The forearm is typically used for intradermal injections, such as tuberculosis (TB) testing. It does not have sufficient muscle mass for intramuscular injections.

C. The abdomen is commonly used for subcutaneous injections, such as insulin or heparin. It is not an appropriate site for intramuscular injections due to insufficient muscle depth and increased risk of improper administration.

D. The upper back is not a standard or recommended site for intramuscular injections. While some areas of the back contain muscle, they are not commonly used due to difficulty in access and risk of injury to underlying structures.