Nokea
A client at 12 weeks' gestation reports nausea and vomiting. What is the best dietary advice?
- A. Eat three large meals a day.
- B. Drink fluids with meals.
- C. Consume small, frequent meals throughout the day.
- D. Avoid protein-rich foods.
Correct Answer: C
Rationale: The correct answer is C: Consume small, frequent meals throughout the day. This advice helps manage nausea and vomiting during pregnancy by preventing an empty stomach, which can worsen symptoms. Eating small, frequent meals helps stabilize blood sugar levels and provides a steady source of nutrients for the developing fetus. It also reduces the likelihood of triggering nausea by avoiding large meals. Drinking fluids with meals (choice B) may exacerbate symptoms by filling up the stomach too quickly. Eating three large meals a day (choice A) can lead to overeating and may worsen nausea. Avoiding protein-rich foods (choice D) is not recommended as protein is essential for fetal development and overall health during pregnancy.
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Which assessment finding indicates uterine rupture?
- A. Contractions abruptly stop during labor
- B. Decreased maternal heart rate
- C. Gradual onset of mild pain during contractions
- D. Uterus becomes firm between contractions
Correct Answer: A
Rationale: The correct answer is A: Contractions abruptly stop during labor. Uterine rupture is a serious obstetric emergency where the integrity of the uterus is compromised, leading to potential life-threatening complications for both the mother and the fetus. When the uterus ruptures, contractions may abruptly stop due to the loss of muscle tone and coordination. This sudden cessation of contractions is a red flag indicating uterine rupture.
Choice B, decreased maternal heart rate, is not typically associated with uterine rupture. Choice C, gradual onset of mild pain during contractions, is more indicative of a normal labor process rather than uterine rupture. Choice D, uterus becomes firm between contractions, is not a specific sign of uterine rupture as it can occur in normal labor as well.
Probable signs of pregnancy
- A. Ballottement (rebounding of the fetus against the examiner's fingers on palpation)
- B. Chadwicks sign (violet coloration of mucous membranes of cervix, vagina, and vulva @4 wks)
- C. Uterine enlargement
- D. Hegar's sign (compressibility and softening of lower uterine segment @6 wks)
Correct Answer: A
Rationale: The correct answer is A: Ballottement. This is a probable sign of pregnancy because it involves the rebounding of the fetus against the examiner's fingers on palpation. This occurs when the examiner pushes against the uterus and feels a bouncing back, indicating the presence of a fetus.
Choice B, Chadwick's sign, is actually the violet coloration of mucous membranes of cervix, vagina, and vulva at around 6-8 weeks, not 4 weeks as stated.
Choice C, uterine enlargement, is a presumptive sign of pregnancy as it can be caused by factors other than pregnancy, such as fibroids.
Choice D, Hegar's sign, involves the compressibility and softening of the lower uterine segment at around 6 weeks, but it is a probable sign rather than a definitive one like Ballottement.
The nurse provides education to the person undergoing a surgical abortion. What response by the person shows an understanding of the education?
- A. “It’s good I won’t have any pain after the procedure.â€
- B. “I think I’m sure about my decision.â€
- C. “I should call if I soak a pad in 2 hours.â€
- D. “I should follow up for contraception counseling at my annual exam in 6 months.â€
Correct Answer: C
Rationale: The correct answer is C because soaking a pad in 2 hours could indicate excessive bleeding, a potential complication after a surgical abortion. This response shows understanding of the education provided by the nurse about when to seek immediate medical attention.
Choice A is incorrect because it is not true that there will be no pain after a surgical abortion; pain is a common experience post-procedure. Choice B is incorrect because it does not demonstrate an understanding of the key information provided during education. Choice D is incorrect because contraception counseling should be addressed sooner than 6 months post-abortion to prevent unintended pregnancies.
What is the best nursing action for a newborn experiencing hypothermia?
- A. Place the newborn in skin-to-skin contact with the mother
- B. Provide a warm blanket and monitor temperature
- C. Administer IV fluids to stabilize temperature
- D. Monitor glucose levels for hypoglycemia
Correct Answer: A
Rationale: The correct answer is A: Place the newborn in skin-to-skin contact with the mother. This is the best nursing action for a newborn experiencing hypothermia because it provides immediate and effective warmth transfer from the mother to the baby. Skin-to-skin contact helps regulate the newborn's body temperature, promotes bonding, and enhances breastfeeding initiation.
Choice B is incorrect because while providing a warm blanket is important, skin-to-skin contact with the mother is more effective in quickly raising the newborn's temperature. Choice C is incorrect because administering IV fluids is not the first-line treatment for hypothermia in newborns. Choice D is incorrect because monitoring glucose levels for hypoglycemia is important but addressing the hypothermia should take precedence.
What is the term for integrating a person's cultural beliefs into their health care?
- A. cultural integrity
- B. culturally responsive care
- C. holistic care
- D. integrative care
Correct Answer: B
Rationale: The correct answer is B: culturally responsive care. This term specifically refers to integrating a person's cultural beliefs into their health care. Culturally responsive care acknowledges and respects the diversity of beliefs and practices among patients. The other choices are incorrect because:
A: cultural integrity does not specifically address the integration of cultural beliefs in health care.
C: holistic care focuses on treating the whole person but does not specifically address cultural beliefs.
D: integrative care typically refers to combining conventional and complementary approaches to health care, not necessarily cultural beliefs integration.