Nokea
A client who is at 24 weeks of gestation and reports daily mild headaches is being cared for by a nurse. Which of the following instructions should the nurse include in the plan of care?
- A. Administer ibuprofen 400 mg twice daily.
- B. Recommend that the client perform conscious relaxation techniques daily.
- C. Give the client ginseng tea with each meal.
- D. Instruct the client to soak in a bath with a water temperature of 105°F for 15 minutes daily.
Correct Answer: B
Rationale: The correct answer is B: Recommend that the client perform conscious relaxation techniques daily. Headaches during pregnancy can be common due to hormonal changes and increased blood volume. The nurse should recommend non-pharmacological interventions like relaxation techniques to manage headaches safely without medication. Conscious relaxation techniques can help reduce stress and tension, potentially alleviating headaches. Ibuprofen (choice A) is not recommended during pregnancy due to potential harm to the fetus. Ginseng tea (choice C) is not safe for pregnant women as it may lead to complications. Soaking in a hot bath (choice D) with a water temperature of 105°F can raise the body temperature, which is not advised during pregnancy as it may harm the baby.
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A client who is pregnant is scheduled for a contraction stress test (CST). Which of the following findings are indications for this procedure? (Select all that apply)
- A. Decreased fetal movement
- B. Intrauterine growth restriction (IUGR)
- C. Postmaturity
- D. All of the Above
Correct Answer: D
Rationale: The correct answer is D, All of the Above.
1. Decreased fetal movement indicates fetal distress, necessitating CST.
2. IUGR implies potential placental insufficiency, requiring CST evaluation.
3. Postmaturity increases risk of placental insufficiency, warranting CST.
Other choices are incorrect as they do not directly indicate the need for CST in a pregnant client.
A client who is at 7 weeks of gestation is experiencing nausea and vomiting in the morning. Which of the following information should the nurse include?
- A. Eat crackers or plain toast before getting out of bed
- B. Awaken during the night to eat a snack
- C. Skip breakfast and eat lunch after nausea has subsided
- D. Eat a large evening meal
Correct Answer: A
Rationale: The correct answer is A: Eat crackers or plain toast before getting out of bed. This recommendation helps alleviate morning sickness by providing a small, easily digestible snack to settle the stomach before getting up. It helps stabilize blood sugar levels and prevent an empty stomach exacerbating nausea.
Explanation for why B, C, and D are incorrect:
B: Awakening during the night to eat a snack can disrupt sleep patterns and is not necessary for managing morning sickness.
C: Skipping breakfast and waiting until lunch may lead to prolonged nausea and low blood sugar levels, worsening symptoms.
D: Eating a large evening meal can increase the likelihood of acid reflux and indigestion, making morning sickness worse.
A client who is 2 hours postpartum is in the taking-hold phase. Which intervention should the nurse plan to implement during this phase of postpartum behavioral adjustment?
- A. Discuss contraceptive options with the client and her partner.
- B. Repeat information to ensure client understanding.
- C. Listen to the client and her partner as they reflect upon the birth experience.
- D. Demonstrate to the client how to perform a newborn bath.
Correct Answer: D
Rationale: The correct answer is D because during the taking-hold phase, the client is focused on learning and mastering new skills related to caring for the newborn. Demonstrating how to perform a newborn bath aligns with this phase as it helps the client gain confidence and competence in newborn care. Discussing contraceptive options (choice A) is more appropriate during the let-go phase. Repeating information (choice B) may be necessary but is not the priority during the taking-hold phase. Listening to the client and her partner reflect on the birth experience (choice C) is important for emotional support but not specifically related to the behavioral adjustments in the taking-hold phase.
A newborn was transferred to the nursery 30 min after delivery. What should the nurse do first?
- A. Confirm the newborn's identification.
- B. Verify the newborn's identification.
- C. Administer vitamin K to the newborn.
- D. Determine obstetrical risk factors.
Correct Answer: B
Rationale: The correct answer is B because verifying the newborn's identification ensures the right baby is in the nursery. It is crucial for patient safety and prevents mix-ups. Confirming identification (choice A) is important but comes after verification. Administering vitamin K (choice C) is a necessary procedure but not the first priority. Determining obstetrical risk factors (choice D) is important but not as immediate as verifying identification. Thus, verifying the newborn's identification should be done first to prevent errors and ensure proper care.
A nurse at an antepartum clinic is caring for a client who is at 4 months of gestation. The client reports continued nausea, vomiting, and scant, prune-colored discharge. The client has experienced no weight loss and has a fundal height larger than expected. Which of the following complications should the nurse suspect?
- A. Hyperemesis gravidarum
- B. Threatened abortion
- C. Hydatidiform mole
- D. Preterm labor
Correct Answer: C
Rationale: The correct answer is C: Hydatidiform mole. At 4 months of gestation, prune-colored discharge indicates possible passage of vesicular tissue characteristic of a molar pregnancy. This, along with continued nausea, vomiting, and larger fundal height, are signs of a hydatidiform mole. Hyperemesis gravidarum (A) typically involves severe nausea and vomiting leading to weight loss, which the client did not experience. Threatened abortion (B) presents with vaginal bleeding and cramping, not prune-colored discharge. Preterm labor (D) is characterized by regular contractions leading to cervical changes, not the symptoms described.