Nokea
is a vitamin supplement prescribed for clients who have hyperemesis gravidarum.
- A. INCORRECT: Ferrous sulfate is a medication used in the treatment of iron deficiency anemia.
- B. CORRECT: Calcium gluconate is the antidote for magnesium sulfate. the baby is inside. What is the nurse9s best response?
- C. "Your baby's umbilical cord is surrounded by connective tissue called Wharton jelly, which prevents compression of the blood vessels and ensures continued nourishment of your baby."
Correct Answer: B
Rationale: Calcium gluconate is indeed the antidote for magnesium sulfate toxicity. In cases where a pregnant client is receiving magnesium sulfate for conditions like preeclampsia, it is important to have calcium gluconate readily available in case of magnesium toxicity. This is a crucial intervention to prevent any adverse effects on both the mother and the baby. So, the nurse should ensure that calcium gluconate is available and be prepared to administer it if needed.
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The nurse is conducting a prenatal class about amniotic fluid. Which characteristics should be included in the teaching?
- A. Allows for fetal movement.
- B. Surrounds, cushions, and protects the fetus.
- C. Maintains the body temperature of the fetus.
- D. Can be used to measure fetal kidney function.
Correct Answer: B
Rationale: Amniotic fluid serves multiple functions, including cushioning the fetus, temperature regulation, and monitoring fetal kidney health.
A nurse is caring for a client who is 4 hr postpartum following a vaginal birth. The client has saturated a perineal pad within 10 min. Which of the following actions should the nurse take first
- A. Assess client's blood pressure.
- B. Assess the bladder for distention.
- C. Massage the client's fundus.
- D. Prepare to administer a prescribed oxytocic preparation.
Correct Answer: B
Rationale: The first action the nurse should take in this situation is to assess the bladder for distention. Postpartum hemorrhage can be caused by a distended bladder putting pressure on the uterus, preventing it from contracting effectively and leading to excessive bleeding. By assessing for bladder distention and ensuring the client empties her bladder, the nurse can help the uterus contract more efficiently and potentially reduce the bleeding. Assessing the other options such as blood pressure, massaging the fundus, and preparing to administer an oxytocic can be important interventions eventually, but addressing the bladder distention is the first priority in this case of excessive postpartum bleeding.
The nurse is educating a client about signs of labor. Which statement indicates understanding?
- A. False labor contractions cause cervical changes.
- B. True labor contractions decrease with activity.
- C. True labor contractions become stronger and more regular.
- D. False labor contractions are felt in the back.
Correct Answer: C
Rationale: True labor is characterized by regular, strong contractions that lead to cervical changes.
A patient asks the nurse about using the basal body temperature method as contraception. What statement made by the patient indicates that the patient needs further teaching?
- A. “I need to take my temperature before I even sit up in bed.â€
- B. “A rise of 0.4° F above my baseline temperatures for 3 days indicates it is safe to have condomless sex.â€
- C. “I need to use a special thermometer to take my basal body temperature.â€
- D. “I know I am about to ovulate when my temperature rises at least 0.4° F.â€
Correct Answer: B
Rationale: Option B is the statement made by the patient that indicates the need for further teaching. In the basal body temperature method of contraception, a sustained temperature rise typically indicates ovulation has already occurred, making it unsafe to have condomless sex. It is the drop in temperature just before ovulation that is used to predict a fertile window. Therefore, a rise in temperature would not indicate that it is safe to have condomless sex. The patient should be educated that the temperature shift indicates the end of the fertile window and that it is safest to avoid unprotected sex during the fertile window.
A nurse is planning care for a newborn who is scheduled to start phototherapy using a lamp. Which of the following actions should the nurse include in the plan?
- A. Apply a thin layer of lotion to the newborn skin every 8 hrs.
- B. Give the newborn 1oz of glucose water every 4 hrs.
- C. Ensure the newborn eyes are closed beneath the shield.
- D. Dress the newborn in a thin layer of clothing during therapy
Correct Answer: C
Rationale: The correct action the nurse should include in the care plan for a newborn undergoing phototherapy using a lamp is to ensure that the newborn's eyes are closed beneath the shield. This is important to protect the newborn's eyes from exposure to the bright light emitted during phototherapy, as prolonged exposure can lead to eye damage. Keeping the eyes closed under the shield helps prevent potential harm and ensures the safety and well-being of the newborn during the treatment. Applying a thin layer of lotion, giving glucose water, or dressing the newborn in clothing are not relevant or appropriate actions for phototherapy care in this scenario.