A client at 6-weeks gestation presents to the office with a report of vaginal bleeding for the last 12 hours without cramping. Which action should the nurse take?

Check serum human chorionic gonadotropin.

Verify the date of the last menstrual cycle.

Inquire about the last occurrence of intercourse.

Repeat a urine pregnancy test.

Answer and Explanation

The Correct Answer is A

Choice A rationale

Checking serum human chorionic gonadotropin (hCG) levels is the appropriate action. hCG levels can help determine the viability of the pregnancy. Decreasing hCG levels may indicate a non-viable pregnancy, while increasing levels suggest a viable pregnancy.

Choice B rationale

Verifying the date of the last menstrual cycle is important but not the priority action in this scenario. While it can provide information on gestational age, it does not directly address the concern of vaginal bleeding.

Choice C rationale

Inquiring about the last occurrence of intercourse is not directly related to assessing the cause of vaginal bleeding. It may provide additional history but does not address the immediate concern.

Choice D rationale

Repeating a urine pregnancy test is not necessary in this context. The client is already known to be pregnant, and a urine test will not provide additional information regarding the cause of the bleeding.

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Correct Answer is A

Explanation

Choice A rationale

Non-nutritive sucking, such as with a pacifier, can be soothing and calming for infants. It helps in the development of oral motor skills and provides comfort during enteral feedings, ensuring that the infant’s need for sucking is met even when they are not feeding.

Choice B rationale

Sterile technique is essential for preventing infections during invasive procedures, but enteral feeding typically does not require such stringent measures. Clean technique is usually sufficient unless the infant has a compromised immune system or other specific medical conditions requiring sterile precautions.

Choice C rationale

While verifying tube placement is critical, it is often done using methods such as pH testing of gastric contents or external marking rather than routine x-rays. Overuse of x-rays exposes infants to unnecessary radiation. X-rays are used primarily when other methods are inconclusive.

Choice D rationale

Instituting physical therapy for a one-month-old infant would not be developmentally appropriate as their primary needs are centered around nutrition, comfort, and growth. Physical therapy is more relevant for older children with developmental or mobility issues rather than infants receiving enteral feedings. .

A. These findings are within normal limits and require routine follow-up. B. All findings are outside of the acceptable range and should be reported to the healthcare provider immediately. C. The primary IV fluids should be increased to assist in increasing the urinary output. D. The findings indicate potential toxicity to the magnesium sulfate and close follow-up is indicated.

Correct Answer is B

Explanation

Choice A rationale

While routine follow-up is necessary, these findings suggest magnesium sulfate toxicity, requiring immediate attention beyond routine monitoring. Hence, this is not the correct action.

Choice B rationale

Although reporting abnormal findings to the healthcare provider is critical, not all findings are necessarily outside acceptable ranges. This choice lacks the specificity needed in this context, making it less appropriate.

Choice C rationale

Increasing primary IV fluids could help with low urine output but would not address potential magnesium toxicity, which is the primary concern indicated by the assessment. Therefore, it is not the correct conclusion.

Choice D rationale

The findings suggest magnesium toxicity, including decreased respirations, reduced urine output, and deep tendon reflexes. Close follow-up, including immediate medical intervention, is needed to manage this potential toxicity.

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A client at 6-weeks gestation presents to the office with a report of vaginal bleeding for the last 12 hours without cramping. Which action should the nurse take?

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Naxlex Comprehensive Predictor Exams

A one-month-old infant admitted to the hospital with dehydration and failure to thrive receives a prescription for enteral feedings. To maintain normal growth and development of the infant, which action should the nurse include?

Correct Answer is A

Explanation

Correct Answer is B

Explanation

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