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A client is reinforcing discharge teaching with a client who has premature rupture of membranes at 26 weeks of gestation. Which of the following instructions should the client include?
- A. Use a condom with sexual intercourse
- B. Avoid bubble bath solution when taking a tub bath
- C. Wipe from front to back when performing perineal hygiene
- D. Keep a daily record of fetal kick counts
Correct Answer: D
Rationale: The correct answer is D: Keep a daily record of fetal kick counts. This is important for monitoring fetal well-being, especially in cases of premature rupture of membranes. By counting fetal kicks daily, the client can assess fetal movements and report any changes promptly to healthcare providers. This helps in early detection of fetal distress or problems.
A: Using a condom with sexual intercourse is not relevant to the situation of premature rupture of membranes.
B: Avoiding bubble bath solution is important for preventing vaginal infections but not directly related to monitoring fetal well-being.
C: Wiping from front to back during perineal hygiene is a general hygiene practice and not specific to the situation of premature rupture of membranes.
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A nurse is teaching clients in a prenatal class about the importance of taking folic acid during pregnancy. The nurse should instruct the clients to consume an adequate amount of folic acid from various sources to prevent which of the following fetal abnormalities?
- A. Neural tube defect
- B. Trisomy 21
- C. Cleft lip
- D. Atrial septal defect
Correct Answer: A
Rationale: The correct answer is A: Neural tube defect. Folic acid is essential for proper neural tube development in the fetus, preventing abnormalities like spina bifida. Consuming an adequate amount of folic acid before and during pregnancy reduces the risk of neural tube defects. Trisomy 21 (choice B) is caused by an extra copy of chromosome 21, not influenced by folic acid intake. Cleft lip (choice C) and atrial septal defect (choice D) have multifactorial causes and are not directly prevented by folic acid consumption.
A nurse in a clinic receives a phone call from a client who would like information about pregnancy testing. Which of the following information should the nurse provide to the client?
- A. You should wait 4 weeks after conception to be tested for pregnancy.
- B. You should be off any medications for 24 hours prior to the pregnancy test.
- C. You should not eat or drink for at least 8 hours prior to the pregnancy test.
- D. You should use your first morning urination specimen for a home pregnancy test.
Correct Answer: D
Rationale: The correct answer is D. Using the first morning urine specimen for a home pregnancy test is recommended because it is more concentrated, increasing the accuracy of the test. This is due to the higher levels of the pregnancy hormone hCG present in the urine after a night of not urinating.
Choice A is incorrect because pregnancy testing can usually be done as early as 1-2 weeks after conception, not necessarily 4 weeks.
Choice B is incorrect as being on medications does not typically affect the accuracy of a pregnancy test.
Choice C is incorrect as there is no need for fasting before a pregnancy test; it does not impact the test results.
A client at 40 weeks of gestation is experiencing contractions every 3 to 5 minutes, becoming stronger. A vaginal exam by the registered nurse reveals the client's cervix is 3 cm dilated, 80% effaced, and -1 station. The client requests pain medication. Which of the following actions should the nurse prepare to take? (Select all that apply)
- A. Provide ice chips.
- B. Insert an indwelling urinary catheter.
- C. Administer opioid analgesic medication.
- D. Provide ice chips.
Correct Answer: C
Rationale: The correct action is to administer opioid analgesic medication (Choice C). At 40 weeks gestation with contractions every 3-5 minutes, 3 cm dilated, 80% effaced, and -1 station, the client is in active labor. Pain medication is appropriate to manage discomfort during labor. Opioid analgesics can help reduce pain intensity while still allowing the client to remain alert and participate in labor. Ice chips (Choice A and D) are not directly related to pain management in labor. Inserting a urinary catheter (Choice B) is not indicated unless there are specific concerns about bladder distention.
A healthcare professional is assessing four newborns. Which of the following findings should the professional report to the provider?
- A. A newborn who is 26 hours old and has erythema toxicum on their face
- B. A newborn who is 32 hours old and has not passed meconium stool
- C. A newborn who is 12 hours old and has pink-tinged urine
- D. A newborn who is 18 hours old and has an axillary temperature of 37.7° C (99.9° F)
Correct Answer: D
Rationale: The correct answer is D because an axillary temperature of 37.7°C (99.9°F) in a newborn is above the normal range and could indicate a fever, which is a significant concern in newborns due to their immature immune systems. Fever in newborns can be a sign of serious infections that require immediate medical attention.
A: Erythema toxicum is a common rash in newborns and typically resolves on its own without medical intervention.
B: Failure to pass meconium stool by 48 hours may be a concern but not as urgent as a fever.
C: Pink-tinged urine in the first few days of life is likely due to uric acid crystals and is considered normal in newborns.
A client who is 12 hours postpartum has a fundus located two fingerbreadths above the umbilicus, deviated to the right of the midline, and less firm than previously noted. Which of the following actions should the nurse take?
- A. Place the client in a side-lying position.
- B. Assist the client to the bathroom to void.
- C. Obtain a prescription for IV oxytocin.
- D. Administer methylergonovine.
Correct Answer: B
Rationale: The correct answer is B: Assist the client to the bathroom to void. This action can help promote uterine contractions by relieving bladder distention, which can cause the fundus to be displaced. Voiding can help the uterus return to its normal position and firmness. Placing the client in a side-lying position (A) may be helpful for fundal massage but addressing bladder distention is the priority. Obtaining a prescription for IV oxytocin (C) or administering methylergonovine (D) are not indicated as first-line interventions for a fundus located above the umbilicus postpartum.