Nokea
A nurse is caring for a client who is 14 weeks of gestation. At which the following locations should the nurse place the Doppler device when assessing the fetal heart rate?
- A. Midline 2 to 3 cm (0.8 to 1.2 in) above the symphysis pubis
- B. Left Upper Abdomen
- C. Two fingerbreadths above the umbilicus
- D. Lateral at the Xiphoid Process
Correct Answer: A
Rationale: When assessing the fetal heart rate in a client who is 14 weeks of gestation, the nurse should place the Doppler device at the midline 2 to 3 cm above the symphysis pubis. This is the appropriate location for detecting the fetal heartbeat at this gestational age. Placing the Doppler device too high on the abdomen may result in difficulty in detecting the fetal heart rate due to the position of the uterus and fetal size. Placing it too low may not capture the fetal heartbeat accurately. Therefore, the midline location above the symphysis pubis provides the best chance for accurate assessment of the fetal heart rate at 14 weeks of gestation.
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A woman is experiencing mittelschmerz and increased vaginal discharge. Her temperature has increased by 0.6°C (1.0°F) over the past 36 hours. This most likely indicates what?
- A. Menstruation is about to begin.
- B. Ovulation will occur soon.
- C. Ovulation has occurred.
- D. She is pregnant, and will not menstruate.
Correct Answer: C
Rationale: Mittelschmerz, or mid-cycle pain, combined with a basal temperature rise and cervical mucus changes, is a sign that ovulation has occurred. These indicators are part of the body's natural fertility signals.
A patient at 24 weeks of gestation reports that she has a glass of wine with dinner every evening. Which rationale should the nurse provide this patient regarding the necessity to eliminate alcohol intake? N R I G B.C M U S N T O
- A. The fetus is placed at risk for altered brain growth.
- B. The fetus is at risk for severe nervous system injury.
- C. The patient will be at risk for abusing other substances as well.
- D. A daily consumption of alcohol indicates a risk for alcoholism.
Correct Answer: A
Rationale: The correct rationale that the nurse should provide to the patient regarding the necessity to eliminate alcohol intake during pregnancy is that the fetus is placed at risk for altered brain growth. Alcohol consumption during pregnancy can lead to a condition known as Fetal Alcohol Syndrome (FAS), which is characterized by various physical and intellectual disabilities in the child. One of the major consequences of alcohol exposure during pregnancy is impaired brain development in the fetus. This can result in cognitive, behavioral, and neurological problems that may persist throughout the child's life. Therefore, it is crucial for pregnant women to completely abstain from alcohol to protect the health and well-being of the developing fetus.
A nurse is providing teaching about expected changes during pregnancy to a client who is at 24 weeks of gestation. Which of the following information should the nurse include?
- A. "Your stomach will empty rapidly"
- B. "You should expect your uterus to double in size"
- C. "You should anticipate nasal stuffiness."
- D. "Your nipples will become lighter in color".
Correct Answer: B
Rationale: Option B, "You should expect your uterus to double in size," is the correct information to include when discussing expected changes during pregnancy at 24 weeks of gestation. By this time, the uterus has significantly expanded to accommodate the growing fetus, which is the most notable physical change during pregnancy. It is essential for the client to understand the normal physiological changes that occur during pregnancy to ensure they are informed and prepared for the expected progression of their pregnancy.
Which finding during a prenatal visit is most concerning in a client at 32 weeks gestation?
- A. Blood pressure of 120/80 mmHg
- B. Mild lower back pain
- C. Weight gain of 2 pounds in one week
- D. Proteinuria of +2 on a urine dipstick
Correct Answer: D
Rationale: Proteinuria is a potential sign of preeclampsia, requiring evaluation.
After her baby's birth a patient wishes to begin breastfeeding. The nurse assists the client by:
- A. Positioning the infant to grasp the nipple to express milk.
- B. Giving the infant a bottle first to evaluate the baby's ability to suck
- C. Leaving them alone and allowing the infant to nurse as long as desired
- D. Touching the infant's cheek adjacent to the nipple to elicit the rooting reflex
Correct Answer: A
Rationale: Positioning the infant to grasp the nipple to express milk is an essential step in helping the patient begin breastfeeding successfully. As a nurse, it is crucial to ensure that the infant is properly latched onto the breast to facilitate effective feeding and milk transfer. This involves positioning the infant in a way that allows them to effectively grasp the nipple, promoting proper suckling and milk production. By assisting the patient in positioning the infant correctly, the nurse is supporting the establishment of successful breastfeeding and ensuring optimal nutrition for the baby.