Nokea
A nurse is caring for a client who is at 41 weeks of gestation and has a positive contraction stress test. For which of the following diagnostic tests should the nurse prepare the client?
- A. Percutaneous umbilical blood sampling
- B. Amnioinfusion
- C. Biophysical profile (BPP)
- D. Chorionic villus sampling (CVS)
Correct Answer: C
Rationale: The correct answer is C: Biophysical profile (BPP). This test evaluates the fetus's well-being by assessing fetal heart rate, fetal breathing movements, fetal movement, fetal tone, and the volume of amniotic fluid. In a client at 41 weeks with a positive contraction stress test, a BPP helps determine if immediate delivery is necessary due to potential fetal distress.
Percutaneous umbilical blood sampling (A) is used to directly sample fetal blood and assess fetal oxygenation but is not typically indicated in this scenario. Amnioinfusion (B) is used to relieve variable decelerations during labor by infusing sterile fluid into the amniotic cavity, which is not relevant to a client at 41 weeks of gestation with a positive contraction stress test. Chorionic villus sampling (D) is an invasive procedure to diagnose genetic abnormalities early in pregnancy and is not indicated for assessing fetal well-being at 41 weeks.
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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.
A nurse is providing dietary teaching to a client who has hyperemesis gravidarum. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will eat foods that taste good instead of balancing my meals.
- B. I will avoid having a snack before I go to bed each night.
- C. I will have a cup of hot tea with each meal.
- D. I will eliminate products that contain dairy from my diet.
Correct Answer: D
Rationale: Rationale:
- Dairy products can exacerbate symptoms of hyperemesis gravidarum due to their high-fat content.
- Eliminating dairy can help reduce nausea and vomiting.
- It shows the client understands the importance of modifying their diet for symptom management.
Incorrect Options:
- A: Choosing taste over balanced meals may not address the client's nutritional needs.
- B: Avoiding bedtime snacks may not directly impact hyperemesis gravidarum symptoms.
- C: Hot tea may not necessarily be beneficial for managing hyperemesis gravidarum.
Summary: Eliminating dairy is crucial in managing hyperemesis gravidarum by reducing symptoms, unlike the other options that may not directly address the condition.
A nurse is admitting a client to the labor and delivery unit when the client states, 'My water just broke.' Which of the following interventions is the nurse's priority?
- A. Perform Nitrazine testing.
- B. Assess the fluid.
- C. Check cervical dilation.
- D. Begin FHR monitoring.
Correct Answer: D
Rationale: The correct answer is D: Begin FHR monitoring. This is the priority because the client's water breaking indicates a potential risk to the fetus, such as umbilical cord compression or prolapse. FHR monitoring helps assess fetal well-being and detect any signs of distress. Performing Nitrazine testing (A) and checking cervical dilation (C) can wait until after ensuring fetal safety. Assessing the fluid (B) may provide some information but does not directly address the immediate concern for fetal well-being.
A nurse is assessing a client who gave birth vaginally 12 hr ago and palpates their uterus to the right above the umbilicus. Which of the following interventions should the nurse perform?
- A. Reassess the client in 2 hr.
- B. Administer simethicone.
- C. Assist the client to empty their bladder.
- D. Instruct the client to lie on their right side.
Correct Answer: C
Rationale: The correct answer is C: Assist the client to empty their bladder. Palpating the uterus above the umbilicus indicates uterine atony, a common cause of postpartum hemorrhage. A full bladder can displace the uterus further, exacerbating the risk of hemorrhage. Emptying the bladder will allow the uterus to contract properly and reduce the risk. Reassessing the client in 2 hours (A) delays immediate intervention. Administering simethicone (B) is for gas relief and not relevant in this situation. Instructing the client to lie on their right side (D) does not address the underlying issue of uterine atony.
A nurse is caring for an infant who has signs of neonatal abstinence syndrome. Which of the following actions should the nurse take?
- A. Monitor blood glucose level every hr.
- B. Place the infant on his back with legs extended.
- C. Initiate seizure precautions.
- D. Provide a stimulating environment.
Correct Answer: C
Rationale: Correct Answer: C - Initiate seizure precautions.
Rationale: Infants with neonatal abstinence syndrome are at risk for seizures due to drug withdrawal. Initiating seizure precautions involves creating a safe environment to prevent injury during a seizure. This includes padding the crib, ensuring a clear space around the infant, and having emergency medications available. Monitoring blood glucose levels every hour (A) is not directly related to neonatal abstinence syndrome. Placing the infant on his back with legs extended (B) is a basic positioning technique and does not address the specific needs of a baby with neonatal abstinence syndrome. Providing a stimulating environment (D) is contraindicated as it can exacerbate symptoms of withdrawal in the infant.