Nokea
A client reports awaking from sleep by contractions that are occurring every five minutes and lasting 30-40 seconds. Which of the following questions should the nurse ask to assess for true labor versus false labor?
- A. When did your contractions begin?
- B. Have you noticed any bloody show or fluid coming from your vagina?
- C. What happens to your contractions when you move about?
- D. Have you felt fetal movement over the last 24 hours?
Correct Answer: B
Rationale: The correct answer is B. The presence of bloody show or fluid coming from the vagina can indicate ruptured membranes, which is a sign of true labor. This is important in determining whether the client is in active labor. Asking about the presence of bloody show or fluid helps differentiate between true and false labor.
Choice A is less relevant as the timing of contractions alone does not distinguish between true and false labor. Choice C is related to assessing the effectiveness of contractions, not differentiating between true and false labor. Choice D is important for assessing fetal well-being but does not help in distinguishing between true and false labor.
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A nurse is caring for a 7-year-old child who is admitted with an asthma exacerbation.
- A. "Monitoring oxygen saturation and respiratory rate daily."'
- B. "Identification and avoidance of factors that trigger symptoms."'
- C. "Monitoring peak flow measurements regularly."'
- D. "Positioning the client upright in a position of comfort."'
Correct Answer: B
Rationale: The correct answer is B because identifying and avoiding triggers helps prevent asthma exacerbations. This proactive approach addresses the root cause of the issue, promoting long-term management. Monitoring oxygen saturation, respiratory rate, and peak flow are important but reactive measures, not addressing the underlying triggers. Positioning upright aids breathing but does not prevent exacerbations.
Which procedure should be avoided for the client known to have a placenta previa?
- A. A non-stress test
- B. A urinary catheterization
- C. A sterile vaginal exam
- D. An abdominal ultrasound
Correct Answer: C
Rationale: The correct answer is C: A sterile vaginal exam. Placenta previa involves the placenta partially or fully covering the cervix, making a vaginal exam risky due to potential disruption of the placenta and causing severe bleeding. This procedure should be avoided to prevent harm to the client and the baby. A: A non-stress test, D: An abdominal ultrasound, and B: A urinary catheterization are safe procedures that do not pose a risk to the client with placenta previa.
A nurse in a prenatal clinic who reports that her menstrual period is 2 wks late. The client appears anxious and asks the nurse if she is pregnant. Which of the following responses should the nurse make?
- A. You can miss your period for several other reasons, describe your typical menstrual cycle.
- B. If you have been sexually active and haven't used protection, it is likely that you are pregnant.
- C. Let's check to see if you have any other signs of pregnancy, have you noticed any abdominal enlargement yet?
- D. Because you have missed your period, you should try taking a home pregnancy test before you start worrying.
Correct Answer: A
Rationale: Correct Answer: A
Rationale: Response A is the most appropriate because it addresses the client's concerns while also gathering more information. By asking the client to describe her typical menstrual cycle, the nurse can explore other potential reasons for the missed period, such as stress or hormonal imbalances. This approach shows empathy and helps the nurse to provide personalized care based on the client's individual situation.
Summary of Other Choices:
B: This response assumes pregnancy without gathering more information or considering other possibilities, potentially causing unnecessary worry or anxiety.
C: Asking about abdominal enlargement is a specific sign of pregnancy and may not be relevant at this early stage. It also does not address the client's anxiety directly.
D: While suggesting a home pregnancy test is important, it does not address the client's anxiety or gather more information about her menstrual cycle.
A nurse is assessing the newborn of a client who took a selective serotonin reuptake inhibitor (SSRI) during pregnancy. Which of the following manifestations should the nurse identify as an indication of withdrawal from an SSRI?
- A. Large for gestational age
- B. Hyperglycemia
- C. Bradypnea
- D. Vomiting
Correct Answer: D
Rationale: The correct answer is D: Vomiting. Newborns exposed to SSRIs in utero may experience withdrawal symptoms, including gastrointestinal issues like vomiting. This is due to the sudden absence of the drug after birth. Choices A, B, and C are unrelated to SSRI withdrawal. Large for gestational age is more indicative of maternal diabetes, hyperglycemia is not a typical SSRI withdrawal symptom, and bradypnea is not commonly associated with SSRI use.
A nurse is reviewing discharge teaching with the parents of a child who has pediculosis.Which of the following should the nurse include in the teaching?
- A. "Children can share scarves and coats ,but not hats or combs."'
- B. "Household pets can carry and transmit lice to people."'
- C. "After washing clothing,hang clothes outside to dry."'
- D. "Seal nonwashable items in plastic bags for 14 days."'
Correct Answer: D
Rationale: The correct answer is D. The nurse should include sealing nonwashable items in plastic bags for 14 days in the teaching for pediculosis. This is important to prevent reinfestation as lice can survive for up to 48 hours without a host. By sealing items in plastic bags for 14 days, any remaining lice or eggs will die off.
Choice A is incorrect because lice can be transmitted through shared hats and combs, not just scarves and coats. Choice B is incorrect as lice do not live on household pets. Choice C is incorrect as hanging clothes outside will not effectively eliminate lice.