Nokea
A nurse is caring for a client who is 36 weeks of gestation and has a prescription for an amniocentesis. For which of the following reasons should the nurse prepare the client for an ultrasound?
- A. To estimate fetal weight
- B. To locate a pocket of fluid
- C. To determine multiparity
- D. To pre-screen for fetal anomalies
Correct Answer: B
Rationale: The correct answer is B: To locate a pocket of fluid. Before performing an amniocentesis procedure, it is essential to locate a pocket of amniotic fluid to ensure the safety of the fetus during the procedure. This is crucial to avoid accidentally puncturing the fetus or placenta. An ultrasound helps in visualizing the amniotic fluid pocket and guiding the needle insertion accurately.
Incorrect Choices:
A: To estimate fetal weight - Estimating fetal weight is not a primary reason for preparing the client for an ultrasound before amniocentesis.
C: To determine multiparity - Multiparity (number of pregnancies) does not directly impact the need for an ultrasound before an amniocentesis.
D: To pre-screen for fetal anomalies - While ultrasounds can detect anomalies, the primary purpose before an amniocentesis is to locate the amniotic fluid pocket, not screen for anomalies.
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At 28 weeks gestation, a woman enters the hospital in preterm labor and receives atocolytic medication to stop labor. Which assessment findings should be reported immediately to the physician?
- A. Fetal heart rate averaging 160 beats/min
- B. Irregular contractions every 15-20 minutes that last 30 seconds before stopping
- C. Maternal temperature 98.8 degrees F, pulse 84, respiratory rate 22, BP 130/70
- D. Ferning pattern of vaginal discharge under a microscope
Correct Answer: D
Rationale: The correct answer is D - Ferning pattern of vaginal discharge under a microscope. This finding indicates rupture of membranes which can lead to infection and necessitates immediate medical attention to prevent harm to the fetus and mother. A: Fetal heart rate of 160 bpm is within normal range. B: Irregular contractions every 15-20 minutes are not indicative of active labor. C: Maternal vital signs are within normal limits and do not pose an immediate threat.
A nurse provided discharge teaching to new parents on how to care for their newborn following circumcision. Which of the following statements by the parents indicates the need for further clarification?
- A. I should not remove the yellow exudate on the end of the penis.
- B. I will clean his penis with each diaper change.
- C. The circumcision will heal completely within a couple of weeks.
- D. I can give him a tub bath in two days.
Correct Answer: D
Rationale: The correct answer is D. Giving the newborn a tub bath in two days after circumcision could increase the risk of infection as the circumcision wound needs time to heal. A sponge bath is recommended until the wound is completely healed. Choice A is correct because yellow exudate is normal during the healing process. Choice B is correct as keeping the area clean is important. Choice C is correct as circumcision typically heals within a couple of weeks.
A nurse is reinforcing teaching to a group of parents about preventing accidental poisoning in preschoolers. Which of the following should the nurse include?
- A. Have syrup of ipecac available in the home.
- B. Explain to preschool children that plants can be eaten only after they are cooked.
- C. Keep labels on containers of toxic substances and never remove them.
- D. Place medications in a cabinet above the sink.
Correct Answer: C
Rationale: The correct answer is C: Keep labels on containers of toxic substances and never remove them. This is important to prevent accidental poisoning in preschoolers as it helps parents and caregivers easily identify and differentiate toxic substances from safe ones. Removing labels can lead to confusion and increase the risk of accidental ingestion. Having syrup of ipecac available (choice A) is no longer recommended as a first-aid treatment for poisoning. Teaching children to cook plants before eating them (choice B) is not a practical or safe approach. Placing medications in a cabinet above the sink (choice D) may not be effective as preschoolers can still access them if the cabinet is not securely locked.
A nurse monitors fetal well-being by means of an external monitor. At the peak of the contractions, the fetal heart rate has repeatedly dropped 30 beats/min below the baseline. Late decelerations are suspected and the nurse notifies the physician. Which is the rationale for this action?
- A. A nuchal cord (cord around the neck) is associated with variable decelerations, not late decelerations.
- B. Variable decelerations (not late decelerations) are associated with cord compression.
- C. Late decelerations are a result of hypoxia. They are not reflective of the strength of maternal contractions.
- D. Late decelerations are associated with uteroplacental insufficiency and are a sign of fetal hypoxia. Repeated late decelerations indicate fetal distress.
Correct Answer: D
Rationale: The correct answer is D because late decelerations are associated with uteroplacental insufficiency, resulting in fetal hypoxia. This is a sign of fetal distress, as indicated by the repeated drops in fetal heart rate during contractions. Late decelerations occur after the peak of the contraction, reflecting the delayed recovery of the fetal heart rate due to inadequate oxygen supply from the placenta. This prompts the nurse to notify the physician for further evaluation and intervention to address the underlying cause of fetal distress. Choices A, B, and C are incorrect because they do not accurately describe the characteristics and causes of late decelerations in fetal monitoring.
A nurse is reviewing discharge teaching with the parents of a child who has pediculosis.Which of the following should the nurse include in the teaching?
- A. "Children can share scarves and coats ,but not hats or combs."'
- B. "Household pets can carry and transmit lice to people."'
- C. "After washing clothing,hang clothes outside to dry."'
- D. "Seal nonwashable items in plastic bags for 14 days."'
Correct Answer: D
Rationale: The correct answer is D. The nurse should include sealing nonwashable items in plastic bags for 14 days in the teaching for pediculosis. This is important to prevent reinfestation as lice can survive for up to 48 hours without a host. By sealing items in plastic bags for 14 days, any remaining lice or eggs will die off.
Choice A is incorrect because lice can be transmitted through shared hats and combs, not just scarves and coats. Choice B is incorrect as lice do not live on household pets. Choice C is incorrect as hanging clothes outside will not effectively eliminate lice.