Nokea
A nurse is caring for a client who has placenta previa. Which of the following findings should the nurse expect?
- A. Firm rigid abdomen
- B. Painless, vaginal bleeding
- C. Uterine hypertonicity
- D. Persistent headache
Correct Answer: B
Rationale: The correct answer is B: Painless, vaginal bleeding. Placenta previa is a condition where the placenta partially or completely covers the cervix, leading to painless, bright red bleeding in the third trimester. This occurs because the placenta is located close to or over the cervical opening, causing it to bleed with minimal trauma. It is important for the nurse to recognize this sign as it can lead to maternal and fetal complications if not managed promptly. Choices A, C, and D are incorrect because they do not align with the typical presentation of placenta previa. A firm rigid abdomen is more indicative of a condition like placental abruption. Uterine hypertonicity is not a common finding in placenta previa. Persistent headache is not a characteristic symptom of placenta previa and may be indicative of other conditions like preeclampsia.
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The nurse is teaching a client and her partner about the technique of counter pressure during labor. Which of the following statements by the nurse is appropriate?
- A. Your partner will apply upward pressure on your lower abdomen between contractions
- B. Your partner will apply continuous from pressure between your thumb and index finger
- C. Your partner will apply pressure to the top of your uterus during contractions
- D. Your partner will apply steady pressure with a tennis ball to your lower back
Correct Answer: D
Rationale: The correct answer is D because applying steady pressure with a tennis ball to the lower back can help relieve lower back pain during labor. This technique targets the sacral area, which can alleviate discomfort and provide comfort. Choice A is incorrect as upward pressure on the lower abdomen may not be effective for pain relief. Choice B is incorrect as applying continuous pressure between the thumb and index finger is not related to counter pressure for labor pain. Choice C is incorrect as pressure on the top of the uterus during contractions is not a recommended technique.
A nurse is providing discharge teaching to a postpartum client about caring for her five-year 5day old male newborn at home. Which of the following statements should the nurse make to the client?
- A. Retract the foreskin to clean your baby's penis during each bath
- B. Use triple antibiotic ointment on your baby's umbilical cord twice per day
- C. Swaddle your baby tightly with legs extended before laying him down to sleep
- D. Notify your baby's pediatrician if he urinates less than 6 times per day
Correct Answer: D
Rationale: The correct answer is D: Notify your baby's pediatrician if he urinates less than 6 times per day. This is important as decreased urine output can indicate dehydration in a newborn, which is a serious concern. It is crucial to monitor the baby's hydration status closely in the early days of life.
A: Retracting the foreskin to clean the baby's penis is not recommended as it can cause harm and is not necessary at this age.
B: Using triple antibiotic ointment on the umbilical cord is not recommended as it can delay the natural healing process.
C: Swaddling the baby tightly with legs extended is not recommended as it can increase the risk of hip dysplasia.
In summary, the other choices are incorrect because they may cause harm or are not recommended practices for caring for a newborn.
A nurse is caring for a client who has gestational diabetes mellitus. Which of the following clinical findings should indicate to the nurse the client has hyperglycemia?
- A. Double vision
- B. Increased urination
- C. Sweating
- D. Dizziness
Correct Answer: B
Rationale: The correct answer is B: Increased urination. Hyperglycemia in gestational diabetes mellitus leads to elevated blood glucose levels, causing the kidneys to work harder to filter and remove excess sugar from the blood. This results in increased urination (polyuria) as the body tries to eliminate the excess glucose through urine. Double vision (A) is more indicative of neurological issues, sweating (C) can be due to various reasons such as anxiety or hormonal changes, and dizziness (D) may be related to blood pressure changes or inner ear problems. Therefore, increased urination is the most specific clinical finding associated with hyperglycemia in gestational diabetes mellitus.
A nurse is caring for a client who is 6 weeks of gestation and reports nausea and vomiting. Which of the following Recommendations should the nurse make?
- A. Avoid Eating snacks before bedtime
- B. Eat high-fat snack before getting out of bed
- C. Drink additional liquids with each meal
- D. Consume food served at cool temperatures
Correct Answer: D
Rationale: The correct answer is D: Consume food served at cool temperatures. This recommendation is based on the fact that pregnant women experiencing nausea and vomiting (commonly known as morning sickness) may find relief by consuming cold or cool foods, as they are less likely to trigger nausea compared to hot or warm foods. Cold foods also tend to have less of a strong smell, which can help reduce nausea. Avoiding snacks before bedtime (choice A) may not necessarily alleviate nausea in the morning. Eating high-fat snacks before getting out of bed (choice B) may worsen nausea. Drinking additional liquids with each meal (choice C) may not address the underlying cause of nausea and could potentially make it worse.
A nurse is caring for a client who is 36 weeks gestation and has MRSA. Which of the following isolation precautions should the nurse initiate?
- A. Droplet
- B. Contact
- C. Airborne
- D. Protective environment
Correct Answer: B
Rationale: The correct answer is B: Contact precautions. MRSA is primarily spread through direct contact with an infected person or contaminated surfaces. By implementing contact precautions, the nurse can prevent the transmission of MRSA to other patients or healthcare workers. Droplet precautions (choice A) are used for diseases spread via respiratory droplets, such as influenza. Airborne precautions (choice C) are for diseases transmitted through small particles in the air, like tuberculosis. Protective environment (choice D) is used for immunocompromised patients to protect them from environmental pathogens. In this scenario, contact precautions are the most appropriate choice to prevent the spread of MRSA.