Nokea
A nurse is caring for a client who is at 38 weeks of gestation. Which of the following actions should the nurse take prior to applying an external transducer for fetal monitoring?
- A. Determine progression of dilatation and effacement.
- B. Perform Leopold maneuvers.
- C. Complete a sterile speculum exam.
- D. Prepare a Nitrazine paper test.
Correct Answer: B
Rationale: The correct answer is B: Perform Leopold maneuvers. Prior to applying an external transducer for fetal monitoring at 38 weeks of gestation, the nurse should perform Leopold maneuvers to determine the position of the fetus, fetal lie, presentation, and engagement. This helps in locating the fetal back and identifying the optimal placement for the transducer. Progression of dilatation and effacement (choice A) is more relevant for labor assessment. Completing a sterile speculum exam (choice C) is not necessary for fetal monitoring. Preparing a Nitrazine paper test (choice D) is used to assess for rupture of membranes, not for applying an external transducer.
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A nurse is teaching about clomiphene citrate to a client who is experiencing infertility. Which of the following adverse effects should the nurse include?
- A. Breast tenderness
- B. Tinnitus
- C. Urinary frequency
- D. Chills
Correct Answer: A
Rationale: The correct answer is A: Breast tenderness. Clomiphene citrate is known to cause breast tenderness as a common adverse effect due to its estrogen-like effects. This occurs because clomiphene citrate can increase estrogen levels in the body, leading to breast discomfort. Tinnitus (B), urinary frequency (C), and chills (D) are not typically associated with clomiphene citrate use. Tinnitus is more commonly linked to ototoxic medications, urinary frequency may occur with diuretics, and chills are often seen with infections or febrile illnesses. Therefore, the nurse should emphasize breast tenderness as a potential side effect of clomiphene citrate to the client.
A nurse is reviewing the medical record of a client who had a vaginal delivery 3 hr ago. Which of the following findings place the client at risk for postpartum hemorrhage? (Select all that apply.)
- A. Labor induction with oxytocin
- B. Newborn weight 2.948 kg (6 lb 8 oz)
- C. Vacuum-assisted delivery
- D. History of uterine atony
- E. History of human papillomavirus
Correct Answer: A,C,D
Rationale: The correct answers are A, C, and D.
A: Labor induction with oxytocin can lead to uterine hyperstimulation, increasing the risk of postpartum hemorrhage.
C: Vacuum-assisted delivery can cause trauma to the birth canal, leading to increased bleeding.
D: History of uterine atony indicates a potential inability of the uterus to contract effectively, increasing the risk of postpartum hemorrhage.
B: Newborn weight and history of human papillomavirus are not directly related to postpartum hemorrhage.
A nurse is providing teaching to the parents of a newborn about the Plastibell circumcision technique. Which of the following information should the nurse include?
- A. The Plastibell will be removed 4 hours after the procedure.
- B. Make sure the newborn’s diaper is snug.
- C. Yellow exudate will form at the surgical site in 24 hours.
- D. Notify the provider if the end of your baby’s penis appears dark red.
Correct Answer: D
Rationale: Correct Answer: D. Notify the provider if the end of your baby’s penis appears dark red.
Rationale: Dark red appearance at the end of the baby's penis could indicate infection or poor blood flow, requiring immediate medical attention to prevent complications. This information is crucial for parents to recognize potential risks post-circumcision.
Summary of other choices:
A: The Plastibell is usually removed after a few days, not 4 hours. Incorrect.
B: Snug diapers can cause irritation. Not relevant to Plastibell circumcision. Incorrect.
C: Yellow exudate forming in 24 hours is normal post-circumcision. Not concerning. Incorrect.
A nurse is caring for a client who is at 36 weeks of gestation and has methicillin-resistant Staphylococcus aureus. Which of the following types of isolation precautions should the nurse initiate?
- A. Droplet
- B. Contact
- C. Protective environment
- D. Airborne
Correct Answer: B
Rationale: The correct answer is B: Contact precautions. Methicillin-resistant Staphylococcus aureus (MRSA) is primarily spread through direct contact with contaminated skin or surfaces. Contact precautions involve wearing gloves and gowns when in contact with the client or the client's environment to prevent the spread of the infection. Droplet precautions are used for infections transmitted through respiratory droplets, such as influenza. Protective environment precautions are for immunocompromised clients. Airborne precautions are for infections transmitted through small droplets that stay in the air for long periods, such as tuberculosis. Therefore, the most appropriate precaution for a client with MRSA at 36 weeks of gestation is contact precautions to prevent transmission of the infection through direct contact.
A nurse is teaching a client who is at 35 weeks of gestation about manifestations of potential pregnancy complications to report to the provider. Which of the following manifestations should the nurse include?
- A. Shortness of breath when climbing stairs
- B. Swelling of feet and ankles at the end of the day
- C. Headache that is unrelieved by analgesia
- D. Braxton Hicks contractions
Correct Answer: C
Rationale: The correct answer is C: Headache that is unrelieved by analgesia. This symptom could indicate a serious condition like preeclampsia, a potentially life-threatening pregnancy complication. The nurse should instruct the client to report this immediately to the provider for further evaluation and management. Shortness of breath when climbing stairs (A), swelling of feet and ankles at the end of the day (B), and Braxton Hicks contractions (D) are common occurrences in pregnancy and not usually indicative of immediate complications. Therefore, they do not require urgent reporting compared to the unrelieved headache as mentioned in choice C.