Nokea
A client is pregnant for the sixth time. She tells the nurse that she has had three elective first-trimester abortions and that she has a son who was born at 40 weeks' gestation and a daughter who was born at 36 weeks' gestation. In calculating the gravidity and para (parity), the nurse determines that the client is:
- A. Gravida 2, para 6
- B. Gravida 6, para 2
- C. Gravida 3, para 6
- D. Gravida 2, para 2
Correct Answer: B
Rationale: The term gravida refers to the number of pregnancies, of any duration, that a woman has had. Parity (para) refers to the number of pregnancies that have progressed past 20 weeks at delivery. Therefore, this client is gravida 6 (pregnant for the sixth time), para 2 (has a son and a daughter). In this case, the correct answer is Gravida 6, para 2. Choices A, C, and D are incorrect as they do not accurately reflect the information provided. Pregnancy outcomes are often described using the GTPAL acronym: gravida (G), term births (T), preterm births (P), abortions (A), and live births (L). Applying this to the client's history, the GTPAL would be G = 6, T = 1, P = 1, A = 3, L = 2, which further confirms the correct answer.
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The home health nurse has made a visit to an 85-year-old female client's home who has recently had surgery to replace her left knee. The client has been discharged from a rehab facility and has been able to walk on her own. The nurse assesses the need for teaching related to fall prevention. What should the nurse include in this teaching plan?
- A. The client should remove all scatter rugs from the floor and minimize clutter.
- B. The client should not get up and move around the house.
- C. The client does not need to install a raised toilet and grab bar because she is able to walk on her own.
- D. The client should wear a robe and socks while walking in the house.
Correct Answer: A
Rationale: Rugs and clutter are a primary cause of falls in the home and should be eliminated if possible to decrease the risk of a fall.
When a client who is having trouble conceiving says to the nurse, 'I have started taking ginseng,' the best response by the nurse is:
- A. "There is some evidence that ginseng may enhance in vitro sperm motility."?
- B. "Some studies show that ginseng enhances in vitro sperm motility."?
- C. "Ginseng is not proven to be effective for infertility; have you considered other options?"?
- D. "It's probably not going to hurt you, but it's also probably not going to help. Let's look at some other alternatives."?
Correct Answer: B
Rationale: Some studies have shown that ginseng enhances in vitro sperm motility, making Choice B the correct response. It directly addresses the client's comments about taking ginseng and provides valuable information regarding its potential effect on sperm motility. Alternative therapies are often sought by couples struggling with infertility, and acknowledging the potential benefits of ginseng can empower the client. Choice A is incorrect as it slightly misrepresents the evidence by overgeneralizing its effectiveness. Choice C dismisses ginseng without acknowledging its potential benefits, potentially closing off a fruitful discussion with the client. Choice D, while neutral, misses the opportunity to validate the client's choice and explore further options collaboratively. It is crucial for nurses to respect clients' choices, provide accurate information, and guide them effectively in exploring different alternatives.
An Rh-negative woman with previous sensitization has delivered an Rh-positive fetus. Which of the following nursing actions should be included in the client's care plan?
- A. emotional support to help the family cope with feelings of guilt about the infant's condition
- B. administration of MICRhoGam to the woman within 72 hours of delivery
- C. administration of Rh-immune globulin to the newborn within 1 hour of delivery
- D. lab analysis of maternal Direct Coombs' test
Correct Answer: A
Rationale: In this scenario, the Rh-negative woman has been sensitized, posing a risk to any Rh-positive fetus she delivers. The most appropriate nursing action is to provide emotional support to help the family cope with the infant's condition. This includes addressing potential outcomes like death or neurological damage. Administering MICRhoGam (Choice B) to a sensitized woman is not recommended; it is only given post-abortion or ectopic pregnancy to prevent sensitization. Rh-immune globulin is not administered to the newborn (Choice C) in this case. Analyzing the maternal Direct Coombs' test (Choice D) is unnecessary; instead, an Indirect Coombs' test is used to assess sensitization. Therefore, the correct nursing action is to offer emotional support to the family, acknowledging the challenges they may face.
A woman who delivered a healthy newborn 6 hours earlier complains of discomfort at the episiotomy site. Which action by the nurse is the most appropriate?
- A. Administering an intravenous (IV) opioid analgesic
- B. Assisting the woman in taking a warm sitz bath
- C. Applying an ice pack to the perineum
- D. Contacting the registered nurse
Correct Answer: C
Rationale: Applying an ice pack to the perineum is the most appropriate action in this scenario. Ice causes vasoconstriction, providing relief by numbing the area and preventing edema. It is typically used within the first 12 to 24 hours after birth. Assisting the woman in taking a warm sitz bath is more suitable after 24 hours as warm water can be soothing. Administering an IV opioid analgesic is excessive; an anesthetic spray is more appropriate for surface discomfort. Contacting the registered nurse is unnecessary as applying an ice pack is within the nurse's scope and can effectively address the discomfort without escalation.
During a routine health screening, the nurse should talk to the parents of a 1-year-old child about which of the following?
- A. the potential hazards of accidents
- B. appropriate nutrition now that the child has been weaned from breast-feeding
- C. toilet training
- D. how to purchase appropriate shoes now that the child is walking
Correct Answer: A
Rationale: Accidents are the primary source of injury in children and can be life threatening. Appropriate nutrition should have been discussed during the weaning process and while the purchase of appropriate shoes is important, it is not life threatening. One year of age is too early to discuss toilet training.