Nokea
A nurse is assessing a client who is at 37 weeks of gestation. Which of the following statement by the client requires immediate intervention by the nurse?
- A. "It burns when I urinate
- B. "My feet are really swollen today".
- C. "didn't have lunch today, but I have breakfast this morning".
- D. "have been seeing spot this morning"
Correct Answer: D
Rationale: Seeing spots or experiencing visual disturbances can be a sign of preeclampsia, a serious pregnancy complication characterized by high blood pressure. Preeclampsia can lead to severe complications for both the mother and the baby, so it requires immediate intervention by the nurse. The other statements made by the client are concerning but do not indicate an urgent need for intervention compared to the symptoms of preeclampsia.
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What is the primary purpose of administering vitamin K to a newborn?
- A. Prevent anemia
- B. Enhance immune function
- C. Prevent bleeding disorders
- D. Promote growth and development
Correct Answer: C
Rationale: Newborns are born with low levels of vitamin K, essential for blood clotting.
A pregnant client asks about the purpose of taking folic acid. What is the nurse's best response?
- A. It prevents gestational diabetes.
- B. It helps prevent neural tube defects.
- C. It supports fetal bone development.
- D. It reduces the risk of preterm labor.
Correct Answer: B
Rationale: Folic acid is essential for preventing neural tube defects like spina bifida during early fetal development.
A nurse is caring for a client who is in the first stage of labor. The nurse observes the umbilical cord protruding from the vagina. Which of the following actions should the nurse perform first?
- A. Cover the cord with a sterile, moist saline dressing.
- B. Prepare the client for an immediate birth.
- C. Place the client in knee-chest position.
- D. Insert a gloved hand into the vagina to relieve pressure on the cord. Rationale: This is the first nursing action because it is essential to prevent any pressure on the umbilical cord to promote oxygenation of the fetus.
Correct Answer: D
Rationale: The correct action for the nurse to perform first when observing the umbilical cord protruding from the vagina during the first stage of labor is to insert a gloved hand into the vagina to relieve pressure on the cord. This is crucial to prevent compression of the cord, which could compromise oxygenation to the fetus. By gently lifting the presenting part off the cord, the nurse can help maintain blood flow and prevent fetal distress. Once the pressure on the cord is relieved, additional interventions such as preparing the client for immediate birth, covering the cord with a sterile, moist saline dressing, or positioning the client in knee-chest position may be necessary depending on the clinical situation. But the priority is to relieve pressure on the umbilical cord promptly to ensure the well-being of the fetus.
Which action by the nurse prevents infection in the labor and birth area?
- A. Keeping under pad and linen as dry as possible
- B. Performing vaginal exam q hour while client in active area
- C. Cleaning secretion from vaginal area using back to front
- D. Using clean technique for all procedures
Correct Answer: D
Rationale: Using clean technique for all procedures helps prevent infection in the labor and birth area. A clean technique involves maintaining cleanliness and limiting contamination during procedures. This includes proper hand hygiene, use of clean gloves, and ensuring that equipment and supplies are kept clean and sterile as needed. By adhering to clean techniques, the nurse reduces the risk of introducing harmful microorganisms into the labor and birth area, ultimately reducing the chances of infection for both the mother and baby. It is important for the nurse to practice proper infection control measures to provide a safe environment for labor and birth.
The nurse assesses a patient for medical eligibility for contraceptive use. What is the meaning of an MEC score of 2?
- A. There is no restriction for the use of the contraceptive method.
- B. There is an unacceptable health risk if the contraceptive method is used.
- C. There is a risk that outweighs the advantages of the contraceptive method.
- D. There is an advantage of using a contraceptive method that outweighs any risk.
Correct Answer: B
Rationale: An MEC score of 2 indicates that there is an unacceptable health risk if the contraceptive method is used. This means that the potential health risks associated with using this particular contraceptive method outweigh the benefits. Therefore, the nurse should advise against using this method for contraception due to the elevated health risks involved. It is essential for healthcare providers to meticulously assess the medical eligibility of a patient before recommending any contraceptive method to ensure the safety and well-being of the individual.