Nokea
A client who is at 12 weeks of gestation is reviewing a new prescription of ferrous sulfate. Which of the following statements by the client indicates understanding of the teaching?
- A. I will take this pill with my breakfast.
- B. I will take this medication with a glass of milk.
- C. I plan to drink more orange juice while taking this pill.
- D. I plan to add more calcium-rich foods to my diet while taking this medication.
Correct Answer: C
Rationale: The correct answer is C: "I plan to drink more orange juice while taking this pill." Orange juice is rich in vitamin C, which enhances the absorption of iron from ferrous sulfate, helping to combat iron deficiency anemia during pregnancy. Taking the pill with a vitamin C source is important for optimal absorption.
A: Taking the pill with breakfast may not provide enough vitamin C for optimal absorption.
B: Milk may inhibit iron absorption due to its calcium content, so it is not ideal to take with ferrous sulfate.
D: While increasing calcium-rich foods is important during pregnancy, it is not directly related to enhancing iron absorption from ferrous sulfate.
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When caring for a client in labor, which of the following infections can be treated during labor or immediately following birth? (Select all that apply)
- A. Gonorrhea
- B. Chlamydia
- C. HIV
- D. All of the Above
Correct Answer: D
Rationale: The correct answer is D: All of the Above. All three infections - Gonorrhea, Chlamydia, and HIV - can be treated during labor or immediately following birth to prevent transmission to the newborn. Antibiotics can be administered for Gonorrhea and Chlamydia, while antiretroviral medications can be given for HIV. Prompt treatment is crucial to reduce the risk of vertical transmission. The other choices are incorrect because each infection listed can be effectively managed during labor or post-birth, making choice D the most comprehensive and accurate option.
A nurse is developing a plan of care for a client who has preeclampsia and is receiving magnesium sulfate via a continuous IV infusion. Which of the following interventions should the nurse include in the plan?
- A. Monitor the client's blood pressure every hour.
- B. Restrict the total hourly intake to 200 mL.
- C. Monitor the FHR continuously.
- D. Administer protamine sulfate for manifestations of toxicity.
Correct Answer: C
Rationale: The correct answer is C: Monitor the FHR continuously. This is essential in preeclampsia as magnesium sulfate can affect fetal heart rate (FHR). Continuous monitoring helps detect any changes promptly.
A: Monitoring blood pressure is important but not as critical as FHR monitoring in this scenario.
B: Restricting total hourly intake to 200 mL is not necessary for magnesium sulfate administration.
D: Administering protamine sulfate is incorrect as it is used for heparin toxicity, not magnesium sulfate toxicity.
A client who is at 8 weeks of gestation tells the nurse, 'I am not sure I am happy about being pregnant.' Which of the following responses should the nurse make?
- A. I will inform the provider that you are having these feelings.
- B. It is normal to have these feelings during the first few months of pregnancy.
- C. You should be happy that you are going to bring new life into the world.
- D. I am going to make an appointment with the counselor for you to discuss these thoughts.
Correct Answer: B
Rationale: Rationale for Correct Answer B: It is normal to have these feelings during the first few months of pregnancy.
1. Acknowledges client's emotions without judgment.
2. Validates the client's experience as common and normal.
3. Provides reassurance and support.
4. Encourages open communication.
Summary of Incorrect Choices:
A. Not necessary to escalate without client's consent.
C. Invalidates client's feelings and imposes expectations.
D. Implies assumption of severity and may be seen as intrusive.
A newborn was delivered vaginally and experienced a tight nuchal cord. Which of the following clinical manifestations should the nurse expect to observe?
- A. Bruising over the buttocks
- B. Hard nodules on the roof of the mouth
- C. Petechiae over the head
- D. Bilateral periauricular papillomas
Correct Answer: C
Rationale: The correct answer is C: Petechiae over the head. This is because tight nuchal cord can cause pressure on the baby's head during delivery, leading to tiny red or purple spots called petechiae due to capillary rupture. Bruising over the buttocks (A) is more common in breech deliveries, hard nodules on the roof of the mouth (B) could indicate Epstein pearls which are benign and common in newborns, and bilateral periauricular papillomas (D) are not related to nuchal cord compression.
A client who is at 15 weeks of gestation, is Rh-negative, and has just had an amniocentesis. Which of the following interventions is the nurse's priority following the procedure?
- A. Check the client's temperature.
- B. Observe for uterine contractions.
- C. Administer Rho(D) immune globulin.
- D. Monitor the fetal heart rate (FHR).
Correct Answer: D
Rationale: The correct answer is D: Monitor the fetal heart rate (FHR). After an amniocentesis, the priority is monitoring FHR to assess fetal well-being and detect any signs of distress. This is crucial as the procedure carries a risk of causing fetal distress. Checking the client's temperature (A) is important but not the priority. Observing for uterine contractions (B) is important but not immediate post-amniocentesis. Administering Rho(D) immune globulin (C) is typically done in cases of Rh incompatibility and not directly related to the amniocentesis procedure.