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
Administering prophylactic antibiotics is essential when there is infection risk, but this intervention is not directly related to managing hemorrhage or neonatal nerve palsy.
Choice B rationale
Jaundice assessment is critical for newborns with facial bruising or cephalohematoma, as bilirubin levels may rise due to blood breakdown in the localized hematoma.
Choice C rationale
Monitoring vital signs ensures maternal stability, though it does not directly address hemorrhage risk or neonatal complications like nerve palsy.
Choice D rationale
Educating the client on breastfeeding techniques provides essential support but does not focus on managing cephalohematoma-related neonatal conditions.
Correct Answer is B
Explanation
Choice A rationale
Peanut butter contains high phenylalanine levels, contraindicated in phenylketonuria. This amino acid accumulates in individuals lacking phenylalanine hydroxylase, causing neurotoxicity and developmental delay.
Choice B rationale
Apples are low in phenylalanine, making them a safe option for individuals with phenylketonuria. They provide essential nutrients without contributing to phenylalanine accumulation.
Choice C rationale
Skim milk is rich in phenylalanine due to its high protein content. Consumption in phenylketonuria leads to amino acid buildup and potential neurological harm.
Choice D rationale
Eggs are protein-dense and therefore contain significant phenylalanine levels. This amino acid must be restricted in phenylketonuria to prevent its toxic effects on the brain. .
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