Question

A nurse is instructing a male patient on how to perform a testicular self-examination. Which piece of information should the nurse include in the teaching?

Answer 1

Correct Answers:

The testicles should be examined after a bath or shower.

Rationale :

🟦 Warm water from a bath or shower relaxes the scrotal sac, making the testicles easier to feel and examine.

🟦 The client should be instructed to gently roll each testicle between the thumb and fingers, feeling for any lumps, swelling, or changes in size, shape, or consistency.

🟦 This technique improves early detection of testicular cancer, which is most common in males aged 15–35 years.

🟦 The exam should be done monthly, not weekly, and pinching is discouraged as it can cause discomfort and doesn’t aid in proper evaluation.

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Answer 2

Correct Answers:

At the level of the umbilicus.

Rationale :

🔹 Within 12 hours after a vaginal delivery, the uterine fundus is typically at or slightly above the level of the umbilicus.

🔹 It should feel firm and midline, indicating effective uterine contraction and reduced risk of postpartum hemorrhage.

🔹 Over the next few days, the fundus will descend approximately 1 cm (one fingerbreadth) per day until it is no longer palpable by about 10–14 days postpartum.

🔹 A fundus displaced to the right may suggest a distended bladder, which can interfere with uterine involution and should be addressed.

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Answer 3

Correct Answers:

Administer the insulin when the breakfast tray arrives.

Rationale :

🔹 Regular insulin is a short-acting insulin that begins to work within 30 minutes after administration and peaks in 2–4 hours.

🔹 Administering it when the food tray arrives ensures that the client can eat soon after injection, reducing the risk of hypoglycemia if a meal is delayed.

🔹 Giving regular insulin too early (e.g., at 0700 or 0730) without immediate food intake could result in hypoglycemia, especially if the breakfast is delayed.

🔹 This timing aligns with safe insulin administration practices and supports blood glucose control while minimizing risk.

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Answer 4

Correct Answers:

Spina bifida.

Rationale :

🟢 Spina bifida is a neural tube defect (NTD) that occurs when the neural tube fails to close properly during early embryonic development. It leads to incomplete formation of the spinal cord and vertebrae, potentially resulting in neurological and physical impairments.

🟢 NTDs like spina bifida typically develop within the first 28 days of pregnancy, often before a woman even knows she's pregnant. This highlights the importance of folic acid supplementation preconception and in early pregnancy to help prevent such defects.

🟢 Cerebral palsy, muscular dystrophy, and hydrocephalus are neurological or muscular disorders but are not classified as neural tube defects. Hydrocephalus may be a complication of spina bifida, but it is not a primary NTD.

🟢 Early screening through maternal serum alpha-fetoprotein (MSAFP) and ultrasound can assist in detecting neural tube defects during pregnancy.

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Answer 5

Correct Answers:

Fetal motion.
Fetal breathing.
Amniotic fluid volume.

Rationale :

🔹Fetal motion (Fetal body movements)

▪️ This refers to gross body movements of the fetus, such as kicking, stretching, or rolling, observed via real-time ultrasound during the biophysical profile (BPP).

▪️ At least three distinct body or limb movements within a 30-minute observation period typically receive a score of 2, indicating reassuring neurologic function.

▪️ Decreased fetal movement may be a sign of fetal hypoxia, CNS depression, or compromised oxygenation, especially in high-risk pregnancies.

▪️ The presence of spontaneous motion reflects an intact central nervous system and adequate oxygenation.

🔹 Fetal breathing (Fetal breathing movements)

▪️ These are rhythmic diaphragmatic movements that mimic breathing, observed through ultrasound and used to assess fetal well-being.

▪️ For a normal score, the fetus must exhibit at least one episode of breathing movement lasting 30 seconds or more within 30 minutes.

▪️ Although the fetus is not actually exchanging air, these movements are important markers of neurologic and respiratory maturity.

▪️ Absence of breathing movements may indicate hypoxemia, neurologic impairment, or fetal distress.

🔹Amniotic fluid volume

▪️ This component evaluates the amount of amniotic fluid using ultrasound to measure the deepest vertical pocket or calculate the amniotic fluid index (AFI).

▪️ An AFI between 5–25 cm or a single pocket >2 cm is considered normal and scores a 2.

▪️ Amniotic fluid levels reflect fetal kidney perfusion and function, since the fetus contributes to fluid volume through urine production.

▪️ Oligohydramnios (low fluid) may suggest placental insufficiency, rupture of membranes, or fetal renal anomalies, while polyhydramnios (high fluid) can be linked to maternal diabetes or fetal anomalies.

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Answer 6

Correct Answers:

Coffee-ground drainage.

Rationale :

☑️ Coffee-ground drainage is characteristic of partially digested blood that has been in the stomach for some time due to an upper gastrointestinal (GI) bleed.

☑️ The acidic environment of the stomach alters hemoglobin, giving the blood a dark brown, granular appearance similar to coffee grounds.

☑️ This finding typically indicates slower or ongoing upper GI bleeding, such as from gastric ulcers, esophageal varices, or gastritis.

☑️ It signals the need for ongoing monitoring, gastric lavage, and possibly endoscopic intervention.

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Answer 7

Correct Answers:

“Moderate exercise improves circulation.”.

Rationale :

✔️ Moderate exercise during pregnancy is beneficial and promotes healthy circulation, reducing the risk of varicose veins, swelling, and blood clots.

✔️ Regular activity also helps maintain healthy weight gain, improves mood, boosts energy, and prepares the body for labor and delivery.

✔️ Safe forms of moderate exercise include walking, swimming, stationary cycling, and prenatal yoga.

✔️ Pregnant individuals should avoid high-impact or contact sports and activities with a high risk of falling or abdominal trauma.

✔️ There’s no recommendation to avoid stretching or to rest before new exercises unless medically indicated.

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Answer 8

Correct Answers:

“This occurs because newborns lack muscle control to regulate eye movement.”.

Rationale :

✅ It is normal for newborns to have intermittent eye crossing or strabismus during the first few months of life due to immature extraocular muscles.

✅ By about 2 to 3 months of age, their eye coordination improves, and the eyes typically begin to align consistently.

✅ Providing this explanation is therapeutic, reassuring the mother with accurate, developmentally appropriate information.

✅ This approach supports parental confidence while reducing unnecessary worry and promotes normal parent–infant bonding.

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Answer 9

Correct Answers:

Schilling test

Rationale :

✅ The Schilling test is a diagnostic test used to determine if the body is properly absorbing vitamin B12, which is essential for red blood cell production.

✅ Pernicious anemia is caused by a deficiency in intrinsic factor, a protein required for vitamin B12 absorption in the ileum.

✅ The test involves giving the patient radioactive vitamin B12 and measuring its excretion in the urine to assess absorption capability.

✅ Low levels of excreted B12 suggest malabsorption, confirming a diagnosis of pernicious anemia.

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Answer 10

Correct Answers:

Turn the patient on her side and recheck the blood pressure.

Rationale :

🔹 A maternal blood pressure of 92/54 mm Hg is hypotensive, especially in the context of a maternal heart rate of 128/min, indicating possible hypovolemia or reduced cardiac output.

🔹 Lying supine in late pregnancy can cause compression of the inferior vena cava by the enlarged uterus, leading to supine hypotensive syndrome, which reduces venous return to the heart and lowers cardiac output.

🔹 The first and safest intervention is to turn the patient onto her side—usually the left side—to relieve vena cava compression and improve blood pressure and fetal perfusion.

🔹 Rechecking BP after repositioning helps confirm whether the low pressure was position-related or requires further medical intervention.

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QLexNursing

1 :
A nurse is instructing a male patient on how to perform a testicular self-examination. Which piece of information should the nurse include in the teaching?

2 :
A nurse is caring for a patient who had a vaginal delivery 12 hours ago. Where should the nurse expect to find the uterine fundus when palpating the patient’s abdomen?

3 :
A nurse is caring for a patient with diabetes and plans to administer regular insulin subcutaneously before breakfast at 0800. After checking the patient’s morning glucose level, what action should the nurse take?

4 :
A nurse is educating a group of pregnant women about neural tube defects. Which of the following conditions should the nurse mention as an example of a neural tube defect?

5 :
A nurse is caring for a patient who is about to undergo a biophysical profile. The patient asks the nurse what will be evaluated during this test. Which of the following should the nurse include? (Select all that apply.)

6 :
A nurse is caring for a patient who has an active upper gastrointestinal bleed. After inserting a nasogastric (NG) tube into the patient, what findings should the nurse anticipate?

7 :
A nurse is educating a group of patients in their first trimester about exercise during pregnancy. Which of the following statements should the nurse include in the teaching?

8 :
A nurse is caring for a new mother who is concerned that her newborn’s eyes cross. Which of the following statements is a therapeutic response by the nurse?

9 :
A nurse is providing care for a patient who the healthcare provider suspects may have pernicious anemia. Which diagnostic test should the nurse anticipate the healthcare provider will order?

QLexNursing

1 : A nurse is instructing a male patient on how to perform a testicular self-examination. Which piece of information should the nurse include in the teaching?

2 : A nurse is caring for a patient who had a vaginal delivery 12 hours ago. Where should the nurse expect to find the uterine fundus when palpating the patient’s abdomen?

3 : A nurse is caring for a patient with diabetes and plans to administer regular insulin subcutaneously before breakfast at 0800. After checking the patient’s morning glucose level, what action should the nurse take?

4 : A nurse is educating a group of pregnant women about neural tube defects. Which of the following conditions should the nurse mention as an example of a neural tube defect?

5 : A nurse is caring for a patient who is about to undergo a biophysical profile. The patient asks the nurse what will be evaluated during this test. Which of the following should the nurse include? (Select all that apply.)

6 : A nurse is caring for a patient who has an active upper gastrointestinal bleed. After inserting a nasogastric (NG) tube into the patient, what findings should the nurse anticipate?

7 : A nurse is educating a group of patients in their first trimester about exercise during pregnancy. Which of the following statements should the nurse include in the teaching?

8 : A nurse is caring for a new mother who is concerned that her newborn’s eyes cross. Which of the following statements is a therapeutic response by the nurse?

9 : A nurse is providing care for a patient who the healthcare provider suspects may have pernicious anemia. Which diagnostic test should the nurse anticipate the healthcare provider will order?

1 :
A nurse is instructing a male patient on how to perform a testicular self-examination. Which piece of information should the nurse include in the teaching?

2 :
A nurse is caring for a patient who had a vaginal delivery 12 hours ago. Where should the nurse expect to find the uterine fundus when palpating the patient’s abdomen?

3 :
A nurse is caring for a patient with diabetes and plans to administer regular insulin subcutaneously before breakfast at 0800. After checking the patient’s morning glucose level, what action should the nurse take?

4 :
A nurse is educating a group of pregnant women about neural tube defects. Which of the following conditions should the nurse mention as an example of a neural tube defect?

5 :
A nurse is caring for a patient who is about to undergo a biophysical profile. The patient asks the nurse what will be evaluated during this test. Which of the following should the nurse include? (Select all that apply.)

6 :
A nurse is caring for a patient who has an active upper gastrointestinal bleed. After inserting a nasogastric (NG) tube into the patient, what findings should the nurse anticipate?

7 :
A nurse is educating a group of patients in their first trimester about exercise during pregnancy. Which of the following statements should the nurse include in the teaching?

8 :
A nurse is caring for a new mother who is concerned that her newborn’s eyes cross. Which of the following statements is a therapeutic response by the nurse?

9 :
A nurse is providing care for a patient who the healthcare provider suspects may have pernicious anemia. Which diagnostic test should the nurse anticipate the healthcare provider will order?