Nokea
A 23-year-old female patient is considering intrauterine device (IUD) contraception. What is the most important information to assess before placement?
- A. Is there any family history of heart disease?
- B. Are you allergic to any metals?
- C. Have you had any previous IUDs inserted?
- D. Do you have a history of hypertension?
Correct Answer: B
Rationale: The correct answer is B: Are you allergic to any metals? This is crucial because some IUDs contain metals like copper, which can trigger allergic reactions in individuals with metal allergies. It is important to assess for metal allergies to prevent potential adverse reactions.
Incorrect Choices:
A: Family history of heart disease is not directly relevant to IUD placement.
C: Previous IUD insertions are important for clinical history but do not impact the initial assessment for a new insertion.
D: History of hypertension is important for overall health assessment but does not directly affect IUD placement.
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A patient 11 weeks' gestation comes to the emergency room department with c/o dizziness, abdominal pain, and shoulder pain. Lab tests reveal a beta-hcg lower than expected level for gestational age
- A. Ultrasound confirms no intrauterine
- B. The nurse knows the most likely diagnostic is an ectopic pregnancy. What statement should the nurse use to explain to the patient?
- C. The baby is in the fallopian tube, the tube has ruptured and is causing bleeding
Correct Answer: B
Rationale: Step 1: Recognize Symptoms - Dizziness, abdominal pain, shoulder pain, low beta-hcg.
Step 2: Consider Ectopic Pregnancy - Symptoms align with ectopic pregnancy.
Step 3: Rule Out Miscarriage - Low beta-hcg indicates not viable intrauterine pregnancy (Choice A).
Step 4: Understand Ectopic Pregnancy - Explaining ectopic pregnancy (Choice C) and rupture to patient may cause distress.
Step 5: Communicate - Nurse should use simple, empathetic statement (Choice B) to explain the likely diagnosis.
Summary: Choice B is correct as it addresses the likely diagnosis without causing undue distress to the patient, unlike Choices A and C which may lead to confusion and anxiety.
A nurse in the emergency department is admitting a client who is at 40 weeks of gestation, has ruptured membranes, and the nurse observes the newborn's head is crowning. The client tells the nurse she wants to push. Which of the following statements should the nurse make? to
- A. "You should go ahead and push to assist the delivery."
- B. "You should try to pant as the delivery proceeds."
- C. "You should try to perform slow-paced breathing."
- D. "You should take a deep, cleansing breath and breathe naturally."
Correct Answer: A
Rationale: The correct answer is A because the newborn's head crowning indicates imminent delivery, and the client's urge to push aligns with the natural progression of labor. By encouraging the client to push, the nurse facilitates the safe and timely delivery of the baby. Panting (choice B) or slow-paced breathing (choice C) may not be effective in this advanced stage of labor. Taking a deep cleansing breath (choice D) can delay the delivery and is not recommended when the baby is crowning.
The nurse is assessing a client in the third trimester with suspected placental abruption. What finding supports this diagnosis?
- A. Painless bright red bleeding.
- B. Boardlike abdomen and severe pain.
- C. Soft, relaxed uterus.
- D. Increased fetal movement.
Correct Answer: B
Rationale: The correct answer is B: Boardlike abdomen and severe pain. This finding supports the diagnosis of placental abruption because it indicates a significant and sudden separation of the placenta from the uterine wall, leading to intense pain and rigidity of the abdomen due to internal bleeding. Painless bright red bleeding (choice A) is more indicative of placenta previa, not placental abruption. A soft, relaxed uterus (choice C) is not typical in placental abruption, which usually presents with uterine tenderness and rigidity. Increased fetal movement (choice D) is not specific to placental abruption and can occur in various pregnancy conditions.
A 28-year-old G1 P0 client tells the nurse that she medication cabergoline, which is effective in reducing has a craving for chalk. What is the nurse's best prolactin levels. What are possible side effects of this response to her?
- A. That is not normal for anyone. We need to refer
- B. Hypotension you to a therapist.
- C. Nasal congestion
- D. Tell me more about why you have a craving for it.
Correct Answer: D
Rationale: Step 1: The nurse should engage the client to gather more information about the craving for chalk. This helps in understanding the underlying cause.
Step 2: By asking the client to elaborate on the reason for the craving, the nurse can assess if it's related to a medical condition or nutritional deficiency.
Step 3: Understanding the client's perspective can guide the nurse in providing appropriate support and interventions.
Step 4: Referring the client to a therapist (option A) without first exploring the issue may not address the root cause effectively.
Step 5: Hypotension (option B) and nasal congestion (option C) are not directly related to the issue of chalk craving, making them incorrect choices.
In summary, option D is correct as it promotes client-centered care by exploring the client's concerns before considering further interventions.
A nurse is monitoring a client who has preeclampsia and is receiving magnesium sulfate by continuous IV infusion. Which of the following findings should the nurse reports to the provider?
- A. Blood pressure 148/94mm Hg
- B. Respiratory rate 14mm
- C. Urinary output 20 mL/hr
- D. 2+deep tendon reflexes
Correct Answer: A
Rationale: The correct answer is A: Blood pressure 148/94mm Hg. High blood pressure in a client with preeclampsia indicates worsening condition and potential for eclampsia. Magnesium sulfate is given to prevent seizures, so high blood pressure needs immediate provider attention.
Incorrect Choices:
B: Respiratory rate 14mm - This respiratory rate is within normal range.
C: Urinary output 20 mL/hr - Low urinary output should be monitored but is not the priority in this situation.
D: 2+deep tendon reflexes - Normal deep tendon reflexes are expected with magnesium sulfate therapy.