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A nurse in a prenatal clinic is assessing a group of clients. Which of the following clients should the nurse see first?
- A. A client who is at 11 weeks of gestation and reports abdominal cramping.
- B. A client who is at 15 weeks of gestation and reports tingling and numbness in right hand.
- C. A client who is at 20 weeks of gestation and reports constipation for the past 4 days.
- D. A client who is at 8 weeks of gestation and reports having three bloody noses in the past week.
Correct Answer: A
Rationale: The correct answer is A. Abdominal cramping in early pregnancy could be a sign of an ectopic pregnancy or miscarriage, both of which are urgent and potentially life-threatening conditions. The nurse should prioritize assessing this client to rule out any serious complications.
Choice B is not as urgent as choice A because tingling and numbness in the hand are likely due to musculoskeletal or nerve compression issues, which are not immediately life-threatening.
Choice C, constipation, is a common issue in pregnancy and is not typically considered an urgent concern unless accompanied by severe symptoms like abdominal pain or bleeding.
Choice D, frequent bloody noses, is not typically an urgent concern in early pregnancy unless it is accompanied by other severe symptoms like dizziness or excessive bleeding.
In summary, the nurse should prioritize assessing the client experiencing abdominal cramping at 11 weeks of gestation due to the potential seriousness of this symptom in early pregnancy.
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A nurse is teaching a client who is at 35 weeks of gestation about manifestations of potential pregnancy complications to report to the provider. Which of the following manifestations should the nurse include?
- A. Shortness of breath when climbing stairs.
- B. Swelling of feet and ankles at the end of the day.
- C. Headache that is unrelieved by analgesia.
- D. Braxton Hicks contractions.
Correct Answer: C
Rationale: The correct answer is C: Headache that is unrelieved by analgesia. This symptom could indicate a potentially serious condition such as preeclampsia, which requires immediate medical attention to prevent complications for the mother and baby. Shortness of breath when climbing stairs (A) is common in late pregnancy due to the growing uterus pressing on the diaphragm. Swelling of feet and ankles (B) is expected in pregnancy due to increased fluid retention. Braxton Hicks contractions (D) are normal and not a cause for concern unless they become regular and closer together.
The nurse suspects the adolescent is experiencing pelvic inflammatory disease and is planning care. Which of the following prescriptions should the nurse expect the provider to prescribe? Drag words from the choices below to fill in each blank in the following sentence. The nurse should anticipate a provider's prescription for---------------------- and ------------------
- A. doxycydline
- B. acyclovir
- C. imiquimod
- D. fluconazole
- E. ceftriaxone
- F. Providing education on medications
Correct Answer: A,E,F
Rationale: The correct answer is A, E, and F. Pelvic inflammatory disease is commonly caused by sexually transmitted infections, such as Chlamydia and Gonorrhea. The recommended treatment involves antibiotics like doxycycline (A) and ceftriaxone (E) to target these infections. Providing education on medications (F) is essential to ensure compliance and understanding of the treatment regimen. Acyclovir (B) is used to treat herpes infections, not PID. Imiquimod (C) is used for certain skin conditions, not PID. Fluconazole (D) is an antifungal medication, not typically used for PID treatment.
A nurse is caring for a newborn who was transferred to the nursery 30 min after birth because of mild respiratory distress. Which of the following actions should the nurse take first?
- A. Confirm the newborn's Apgar score.
- 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: Verify the newborn's identification. This should be done first to ensure the right baby is receiving care. Confirming the identity helps prevent errors in medication administration and procedures. Checking the identification is crucial for patient safety. The other options are not the first priority in this scenario. A: Confirming the Apgar score can wait until after ensuring the correct baby is being cared for. C: Administering vitamin K is important, but verifying identification takes precedence. D: Determining obstetrical risk factors can be done later once the baby's identity is confirmed.
A nurse is admitting a client to the labor and delivery unit when the client states, 'My water just broke.' Which of the following interventions is the nurse's priority?
- A. Perform Nitrazine testing.
- B. Assess the fluid.
- C. Check cervical dilation.
- D. Begin FHR monitoring.
Correct Answer: D
Rationale: The correct answer is D: Begin FHR monitoring. This is the priority intervention because it assesses the well-being of the fetus immediately after the client's water breaking. Monitoring the fetal heart rate can provide crucial information on the baby's status and help identify any signs of distress. Performing Nitrazine testing (A) or checking cervical dilation (C) can be done after ensuring fetal well-being. Assessing the fluid (B) can confirm if the amniotic sac has indeed ruptured but does not provide immediate information on fetal status.
Which of the following actions should the nurse plan to implement? For each potential nursing action, click to specify if the intervention is Indicated or contraindicated for the newborn
- A. Educate the parents to begin range of motion exercises on the affected arm after 1 week.
- B. Assess for grasp reflex in the affected extremity.
- C. Immobilize the arm across the abdomen by pinning the newborn's sleeve to their shirt.
- D. Instruct parents to limit physical handling for 2 weeks.
Correct Answer: B
Rationale: [0, 1, 0, 0]
Assess for grasp reflex in the affected extremity is the correct answer. This action is indicated as it allows the nurse to evaluate neurological function and muscle strength in the affected arm without causing harm. Educating parents to begin range of motion exercises after 1 week (A) is contraindicated as it may exacerbate injury or delay healing. Immobilizing the arm across the abdomen (C) is also contraindicated as it can restrict movement and hinder recovery. Instructing parents to limit physical handling for 2 weeks (D) is not the best option as it may not provide the necessary assessment and treatment for the newborn's condition.