Nokea
A nurse is assisting the nurse manager with an educational session about ways to prevent TORCH infections during pregnancy with a group of newly licensed nurses. Which of the following statements by one of the session participants indicates understanding?
- A. Seeking an immunization against rubella early in pregnancy.
- B. Receiving prophylactic treatment for cytomegalovirus if detected during pregnancy.
- C. Clients should avoid crowded places during pregnancy.
- D. Clients should avoid consuming undercooked meat while pregnant.
Correct Answer: D
Rationale: The correct answer is D. Clients should avoid consuming undercooked meat while pregnant to prevent toxoplasmosis, a TORCH infection. Toxoplasmosis is commonly found in undercooked meat and can be harmful to the fetus. Seeking an immunization against rubella early in pregnancy (A) is important, but it does not prevent all TORCH infections. Prophylactic treatment for cytomegalovirus if detected during pregnancy (B) is not a standard practice. Avoiding crowded places during pregnancy (C) may reduce the risk of infections, but it is not specific to TORCH infections.
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A client in labor requests epidural anesthesia for pain control. Which of the following actions should the nurse include in the plan of care?
- A. Position the client supine for 30 minutes after the first dose of anesthetic solution.
- B. Administer 1,000 mL of dextrose 5% in water after the first dose of anesthetic solution.
- C. Monitor the client's blood pressure every 5 minutes after the first dose of anesthetic solution.
- D. Ensure the client has been NPO for 4 hours before the placement of the epidural and the first dose of anesthetic solution.
Correct Answer: C
Rationale: The correct answer is C: Monitor the client's blood pressure every 5 minutes after the first dose of anesthetic solution. This is crucial as epidural anesthesia can cause hypotension, which can lead to maternal and fetal complications. Monitoring blood pressure every 5 minutes allows for early detection and intervention.
A: Positioning the client supine for 30 minutes after the first dose of anesthetic solution can lead to hypotension due to decreased venous return, so this is incorrect.
B: Administering dextrose 5% in water is not a standard practice after epidural anesthesia and does not address the risk of hypotension, so this is incorrect.
D: Ensuring the client has been NPO for 4 hours before the procedure is important for general anesthesia but not specifically for epidural anesthesia, so this is incorrect.
A client is in labor, and a nurse observes late decelerations on the electronic fetal monitor. What should the nurse identify as the first action that the registered nurse should take?
- A. Assist the client into the left-lateral position
- B. Apply a fetal scalp electrode
- C. Insert an IV catheter
- D. Perform a vaginal exam
Correct Answer: A
Rationale: The correct answer is A: Assist the client into the left-lateral position. This is the first action because it helps improve placental perfusion, which can alleviate late decelerations associated with uteroplacental insufficiency. The left-lateral position promotes optimal blood flow and oxygenation to the placenta by reducing pressure on the vena cava and improving maternal perfusion. This position can potentially prevent further fetal distress.
Summary of other choices:
B: Applying a fetal scalp electrode is not the first action for addressing late decelerations. It may be considered later for more precise monitoring.
C: Inserting an IV catheter is important but not the priority when late decelerations are observed.
D: Performing a vaginal exam is not indicated as the first action for addressing late decelerations and could potentially increase the risk of infection.
A client who is at 36 weeks of gestation and has a prescription for a nonstress test is being taught by a nurse. Which of the following statements should the nurse include in the teaching?
- A. You will receive IV fluid before this test.
- B. The procedure will take approximately 10 to 15 minutes.
- C. You will be offered orange juice to drink during the test.
- D. You will need to sign an informed consent form before each test.
Correct Answer: C
Rationale: The correct answer is C: "You will be offered orange juice to drink during the test." This statement is correct because providing orange juice to the client during the nonstress test can stimulate fetal movement, making it easier to monitor the baby's heart rate. This can help in obtaining a more accurate assessment of the baby's well-being.
Incorrect options:
A: IV fluid administration is not typically required for a nonstress test, so this statement is incorrect.
B: The procedure can actually take longer than 10 to 15 minutes, depending on various factors, so this statement is inaccurate.
D: Informed consent is usually obtained once, not before each test, so this statement is not necessary for the client to know in this context.
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 healthcare provider in a clinic is reinforcing teaching with a client of childbearing age about recommended folic acid supplements. Which of the following defects can occur in the fetus or neonate as a result of folic acid deficiency?
- A. Iron deficiency anemia
- B. Poor bone formation
- C. Macrosomic fetus
- D. Neural tube defects
Correct Answer: D
Rationale: The correct answer is D: Neural tube defects. Folic acid is crucial for neural tube development in the fetus. Without sufficient folic acid, neural tube defects like spina bifida can occur. Iron deficiency anemia (A) is not directly related to folic acid deficiency. Poor bone formation (B) is more associated with calcium and vitamin D deficiencies. Macrosomic fetus (C) refers to excessive fetal growth, not a direct consequence of folic acid deficiency. In summary, folic acid deficiency primarily increases the risk of neural tube defects in the fetus or neonate.