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What is the rationale for a woman in her first trimester of pregnancy to expect to visit her health care provider every 4 weeks?
- A. Problems can be eliminated.
- B. She develops trust in the health care team.
- C. Her questions about labor can be answered.
- D. The conditions of the expectant mother and fetus can be monitored.
Correct Answer: D
Rationale: The correct answer is D because in the first trimester, regular monitoring is crucial to ensure the health and well-being of both the mother and fetus. Visiting every 4 weeks allows the healthcare provider to monitor the progress of the pregnancy, detect any potential issues early on, and provide appropriate interventions if needed. This frequency enables timely adjustments to care plans, such as dietary recommendations or medication changes, to optimize outcomes. Choices A, B, and C are incorrect as they do not directly relate to the primary reason for the regular visits during the first trimester, which is to monitor the conditions of the expectant mother and fetus.
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The nurse is preparing to teach a client how to perform daily fetal kick counts. Which instruction is most important for the nurse to give the client?
- A. Count fetal kicks prior to eating a meal
- B. Lie on back when counting kicks
- C. Call provider if at least three movements are not felt in 1 hour
- D. Count all movements over 1 hour
Correct Answer: C
Rationale: The correct answer is C: Call provider if at least three movements are not felt in 1 hour. This instruction is crucial because decreased fetal movements can indicate potential fetal distress. By advising the client to contact the healthcare provider if fewer than three movements are felt in an hour, the nurse is emphasizing the importance of promptly seeking medical attention when there may be a concern for the baby's well-being.
A: Counting kicks prior to eating a meal is not as important as monitoring the baby's movements consistently throughout the day.
B: Lying on the back when counting kicks is not recommended, as it can reduce blood flow to the uterus and potentially affect the baby.
D: Counting all movements over 1 hour may not capture a decrease in movements that could be a cause for concern, as the focus should be on monitoring a specific minimum number of movements within a set timeframe.
In summary, the correct answer emphasizes the need for prompt action in case of decreased fetal movements, while
The health care provider reports that the primigravida's fundus can be palpated at the umbilicus. Which priority question will the nurse include in the patient's assessment?
- A. Have you noticed that it is easier for you to breathe now?'
- B. Would you like to hear the baby's heartbeat for the first time?'
- C. Have you felt a fluttering sensation in your lower pelvic area yet?'
- D. Have you recently developed any unusual cravings, such as for chalk or dirt?'
Correct Answer: C
Rationale: The correct answer is C: "Have you felt a fluttering sensation in your lower pelvic area yet?" This is the correct question to ask because feeling a fluttering sensation in the lower pelvic area is indicative of quickening, which typically occurs around 18-20 weeks of pregnancy. Quickening is an important milestone in pregnancy that signifies fetal movement. Palpating the fundus at the umbilicus suggests the pregnancy is around 20 weeks, so asking about quickening confirms fetal viability and normal development.
Choice A is incorrect because fundal height does not correlate with ease of breathing. Choice B is incorrect as hearing the baby's heartbeat for the first time is not directly related to fundal height. Choice D is incorrect as unusual cravings are not typically associated with fundal height assessment.
A postpartum client, who delivered her baby vaginally 2 hours earlier, just voided 100 mL in the bathroom. After returning to bed, the nurse makes the following assessment: fundus 4 cm above the umbilicus and deviated to the right with moderate lochia rubra. Which of the following nursing diagnoses is appropriate at this time?
- A. Impaired skin integrity.
- B. Fluid volume deficit.
- C. Impaired urinary elimination.
- D. Toileting self-care deficit.
Correct Answer: C
Rationale: A deviated fundus and moderate lochia rubra suggest urinary retention, which can impede uterine involution.
A baby is born addicted to crack cocaine. Which of the following signs/symptoms would the nurse expect to see?
- A. Hyperreflexia.
- B. Anorexia.
- C. Constipation.
- D. Hypokalemia.
Correct Answer: A
Rationale: Neonates born addicted to crack cocaine often exhibit hyperreflexia, irritability, and other signs of withdrawal.
A nurse is teaching about the effects of globalization. Which information should the nurse include in the teaching session?
- A. Increased spread of communicable diseases
- B. Increased homogeneous mix of nursing staff
- C. Decreased poverty and increased 'health tourism'
- D. Decreased urbanization as populations shift to the suburbs
Correct Answer: A
Rationale: Although globalization of trade, travel, and culture has improved the availability of health care services, the spread of communicable diseases such as tuberculosis and severe acute respiratory syndrome (SARS) has become more common.