Nokea
The nurse is caring for a client in labor who reports intense pressure and the urge to push. What is the priority nursing action?
- A. Perform a sterile vaginal examination.
- B. Instruct the client to breathe through the urge to push.
- C. Notify the healthcare provider.
- D. Increase the oxytocin infusion rate.
Correct Answer: A
Rationale: A vaginal examination is needed to confirm full cervical dilation and readiness for delivery.
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A nurse is providing teaching to a group of women about risk factors for ovarian cancer. Which of the following should the nurse include? (Select all that apply.)
- A. Nulliparity
- B. History of breastfeeding (???)
- C. Previous use of oral contraceptives
- D. History of breast cancer
Correct Answer: A
Rationale: A. Nulliparity: Women who have never been pregnant (nulliparity) are at an increased risk for ovarian cancer compared to women who have had full-term pregnancies. This is thought to be due to the protective effect of pregnancy and childbirth on the ovaries.
The nurse is assessing a client with suspected preeclampsia. What symptom supports this diagnosis?
- A. Hyperglycemia.
- B. Proteinuria.
- C. Increased fetal movement.
- D. Hypotension.
Correct Answer: B
Rationale: Proteinuria is a hallmark symptom of preeclampsia, along with hypertension and other systemic findings.
The nurse is monitoring a pregnant client with gestational hypertension. What is the primary complication to prevent?
- A. Preterm labor.
- B. Placenta previa.
- C. Eclampsia.
- D. Abruptio placentae.
Correct Answer: C
Rationale: Gestational hypertension can progress to eclampsia, characterized by seizures, and requires close monitoring.
A patient is taking oral contraceptives and asks whether they will still be effective if she has diarrhea. What should the nurse respond?
- A. Oral contraceptives will still work if taken with food.
- B. Oral contraceptives may be less effective during diarrhea due to absorption issues.
- C. Oral contraceptives need to be stopped for 7 days when experiencing diarrhea.
- D. Oral contraceptives will be more effective during diarrhea due to faster metabolism.
Correct Answer: B
Rationale: Diarrhea can reduce the absorption of oral contraceptives, potentially making them less effective. Choice A is incorrect because food does not always affect oral contraceptive absorption. Choice C is incorrect because there is no need to stop the contraceptives, but additional methods may be recommended during diarrhea. Choice D is incorrect because diarrhea does not increase the effectiveness of oral contraceptives.
A newborn has a respiratory rate of 80 breaths/min, nasal flaring with sternal retractions, a heart rate of 120 beats/min, temperature of 36C and a persisting oxygen saturation of <87%. The nurse interprets these findings as:
- A. Cardiac distress
- B. Respiratory Alkalosis
- C. Bronchial pneumonia
- D. Respiratory Distress
Correct Answer: D
Rationale: The newborn's presentation with a respiratory rate of 80 breaths/min, nasal flaring with sternal retractions, a heart rate of 120 beats/min, and persisting low oxygen saturation (<87%) are indicative of respiratory distress. These signs suggest that the newborn is having difficulty breathing and may not be getting enough oxygen into their system. Respiratory distress in newborns is a serious condition that requires immediate attention and intervention to support breathing and oxygenation. It is crucial for healthcare providers to recognize and address respiratory distress promptly to prevent further complications.