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When a pregnant woman develops ptyalism, which guidance should the nurse provide?
- A. Chew gum or suck on lozenges between meals.
- B. Eat nutritious meals that provide adequate amounts of essential vitamins and minerals.
- C. Take short walks to stimulate circulation in the legs and elevate the legs periodically.
- D. Use pillows to support the abdomen and back during sleep.
Correct Answer: A
Rationale: The correct answer is A: Chew gum or suck on lozenges between meals. Ptyalism is excessive saliva production during pregnancy. Chewing gum or sucking on lozenges can help manage excessive saliva by promoting swallowing and reducing the sensation of saliva accumulation. This guidance addresses the symptom directly. Choices B, C, and D do not specifically address ptyalism. B focuses on nutrition, C on circulation, and D on physical comfort, which are important aspects of pregnancy but not directly related to managing ptyalism.
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The nurse has received change of shift report on the following four clients. Which of the clients should the nurse assess first?
- A. G1 P0000, 9 weeks’ gestation, hyperemesis gravidarum, vomited twice during the last shift.
- B. G2 P0101, 24 weeks’ gestation, receiving terbutaline po q 2 h for preterm labor, no complaints of cramping during last shift.
- C. G1 P0000, 1 day postpartum, vacuum extraction, for bilateral tubal ligation during this shift.
- D. G2 P0101, 2 days postpartum, spontaneous delivery, had asthma attack during last shift.
Correct Answer: D
Rationale: The client who had an asthma attack during the last shift should be assessed first due to the potential for respiratory complications.
A baby is born addicted to crack cocaine. Which of the following signs/symptoms would the nurse expect to see?
- A. Hyperreflexia.
- B. Anorexia.
- C. Constipation.
- D. Hypokalemia.
Correct Answer: A
Rationale: Neonates born addicted to crack cocaine often exhibit hyperreflexia, irritability, and other signs of withdrawal.
The nurse is obtaining the first postpartum meal for a client who has stated that she practices Mormonism (the Church of Jesus Christ of Latter-Day Saints). Which of the following items should the nurse remove from the clients’ food tray?
- A. Caffeinated coffee.
- B. Cheeseburger.
- C. Fried fish.
- D. Pork sausage.
Correct Answer: A
Rationale: Mormons typically avoid caffeinated beverages as part of their religious practices.
A patient at 36 weeks gestation is undergoing a nonstress (NST) test. The nurse observes the fetal heart rate baseline at 135 beats per minute (bpm) and four nonepisodic patterns of the fetal heart rate reaching 160 bpm for periods of 20 to 25 seconds each. How will the nurse record these findings?
- A. NST positive, nonreassuring
- B. NST negative, reassuring
- C. NST reactive, reassuring
- D. NST nonreactive, nonreassuring
Correct Answer: C
Rationale: Step 1: The baseline fetal heart rate is 135 bpm, which is within the normal range of 110-160 bpm.
Step 2: The four nonepisodic patterns of fetal heart rate reaching 160 bpm for 20-25 seconds each indicate accelerations, a positive sign.
Step 3: A reactive NST requires at least two accelerations of the fetal heart rate within a 20-minute window, which this scenario meets.
Step 4: Therefore, the nurse will record these findings as NST reactive, reassuring because the fetal heart rate responded appropriately to stimuli.
Summary of Other Choices:
A: NST positive, nonreassuring - Inaccurate, as the findings indicate a reassuring response.
B: NST negative, reassuring - Incorrect, as the test results are actually reactive, not negative.
D: NST nonreactive, nonreassuring - Wrong, as the test is reactive and reassuring, not nonreactive and nonreassuring.
The nurse reports a nonreactive NST to the physician. The physician orders vibroacoustic stimulation. Which does the nurse understand the appropriate application for the vibroacoustic stimulation to be? Select all that apply.
- A. Clap loudly by the fetal head
- B. Apply a sterile drape to abdomen prior to stimulation
- C. Apply the artificial larynx stimulus by the fetal head
- D. Limit the use of the artificial larynx stimulus to three times
Correct Answer: C
Rationale: The correct answer is C: Apply the artificial larynx stimulus by the fetal head. Vibroacoustic stimulation involves using sound waves to stimulate the fetus and provoke a response, particularly in cases of nonreactive nonstress test (NST). By applying the artificial larynx stimulus near the fetal head, the nurse ensures direct and effective stimulation of the fetus. This method has been found to be safe and effective in improving fetal heart rate reactivity.
Incorrect Choices:
A: Clap loudly by the fetal head - This is not an appropriate method for vibroacoustic stimulation as it may not provide the controlled and targeted stimulation needed.
B: Apply a sterile drape to abdomen prior to stimulation - This is not necessary for vibroacoustic stimulation and does not contribute to its effectiveness.
D: Limit the use of the artificial larynx stimulus to three times - There is no specific limit to the number of times vibroacoustic stimulation can be applied, as it depends on the