A nurse conducts a physical exam of a client who reports feeling well.
Findings include:
General: No acute distress.
Cardiovascular: No murmur or rub.
Respiratory: Bilateral breath sounds clear.
Abdomen: Fundal height 38 cm.
Genitourinary: Purulent cervical discharge.
The Correct Answer is E
Choice A rationale
No acute distress indicates the client's physiological stability. It reflects an absence of acute systemic responses like tachycardia or labored breathing, suggesting normal homeostasis during examination.
Choice B rationale
No cardiovascular murmurs or rubs imply normal valve function and an absence of pericardial inflammation. This finding indicates no pathological blood flow changes or cardiac friction sounds.
Choice C rationale
Clear bilateral breath sounds suggest open airways and proper ventilation, excluding lower respiratory tract issues like pneumonia. Normal respiratory examination confirms adequate pulmonary function.
Choice D rationale
Fundal height at 38 cm corresponds to late-third trimester pregnancy. It reflects uterine enlargement due to fetal growth, indicating gestational progression but unrelated to cervical discharge.
Choice E rationale
Purulent cervical discharge suggests an ongoing infection, likely bacterial cervicitis. It reflects leukocyte accumulation due to pathogenic invasion, requiring clinical intervention to prevent complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Hyporeactivity is not typically associated with neonatal abstinence syndrome. Common indicators include heightened sensory sensitivity and autonomic dysregulation, leading to hyperactivity rather than hyporeactivity.
Choice B rationale
Excessive high-pitched crying results from central nervous system hyperirritability caused by withdrawal. Neonatal abstinence syndrome involves exaggerated responses to stimuli, reflecting the neonate’s difficulty in self-regulation.
Choice C rationale
Acrocyanosis, or bluish discoloration of the extremities, is a normal finding in newborns and not a specific indicator of neonatal abstinence syndrome. It resolves as circulation improves post-birth.
Choice D rationale
A respiratory rate of 50/min is within the normal range for neonates (30–60/min). Neonatal abstinence syndrome often presents with tachypnea, highlighting autonomic nervous system dysregulation.
Correct Answer is D
Explanation
Choice A rationale
IUD replacement depends on the type. For instance, hormonal IUDs typically last 3-5 years, and copper IUDs can last up to 10 years. Annual replacement is unnecessary.
Choice B rationale
Spermicide use is unnecessary with an IUD as its primary function is to prevent fertilization. This statement reflects a lack of understanding of IUD mechanisms.
Choice C rationale
Periods may become lighter or irregular with hormonal IUDs, but they rarely stop completely. Copper IUDs may actually increase menstrual flow in some cases.
Choice D rationale
Checking for the string ensures proper IUD positioning and functionality. This monthly practice helps detect dislodgement or expulsion, which can compromise contraceptive effectiveness.
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