Nokea
A nurse is caring for a client who is in active labor with a fetus in the occipitoposterior position. The nurse assists the client into a hands-and-knees position. Which of the following questions should the nurse ask to evaluate the effectiveness of this intervention?
- A. Does that lessen your suprapubic pain?
- B. Are you feeling relief from your pelvic pressure?
- C. Do your contractions feel further apart?
- D. Has your back labor improved?
Correct Answer: D
Rationale: The correct answer is D: "Has your back labor improved?" In the occipitoposterior position, the baby's head is pressing against the mother's back, causing intense back pain. Placing the client in a hands-and-knees position can help alleviate this discomfort by encouraging the baby to rotate into a more favorable position. By asking if the back labor has improved, the nurse can directly assess the effectiveness of the intervention.
Incorrect choices:
A: "Does that lessen your suprapubic pain?" - This question is not directly related to the occipitoposterior position or the hands-and-knees intervention.
B: "Are you feeling relief from your pelvic pressure?" - While pelvic pressure may be present, the primary concern with the occipitoposterior position is back labor.
C: "Do your contractions feel further apart?" - Contractions may not necessarily change in frequency with a change in position, especially in cases of fetal malposition.
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A nurse is assessing a full-term newborn upon admission to the nursery. Which of the following clinical findings should the nurse report to the provider?
- A. Single palmar creases (p200
- B. Down Syndrome)
- C. Rust-stained urine
- D. Transient circumoral cyanosis
- E. Subconjunctival hemorrhage
Correct Answer: A
Rationale: The correct answer is A: Single palmar creases. This finding could indicate potential chromosomal abnormalities like Down Syndrome. It is crucial to report this to the provider for further evaluation and appropriate management. Rust-stained urine (C), transient circumoral cyanosis (D), and subconjunctival hemorrhage (E) are common findings in newborns and usually resolve spontaneously without causing harm. Reporting these would not be necessary unless they persist or worsen.
A nurse is providing prenatal teaching to a client who practices a vegan diet and is trying to increase intake of vitamin B12. Which of the following foods should the nurse recommend?
- A. Fortified soy milk
- B. Raw carrots
- C. Fresh citrus fruits
- D. Brown rice
Correct Answer: A
Rationale: The correct answer is A: Fortified soy milk. Soy milk is often fortified with vitamin B12, making it a suitable option for a client following a vegan diet. Vitamin B12 is primarily found in animal products, so vegans need to ensure they get an adequate intake from fortified foods or supplements. Raw carrots (B), fresh citrus fruits (C), and brown rice (D) do not contain significant amounts of vitamin B12 and would not be effective in increasing intake. A detailed explanation is crucial in guiding the client to make informed choices for their dietary needs.
A nurse is providing discharge instructions to a client who is breastfeeding her newborn. Which of the following instructions should the nurse include?
- A. Feed the newborn 5 to 10 min per breast.
- B. Offer the newborn 30 mL (1 oz) of water between feedings.
- C. Expect two to four wet diapers every 24 hr.
- D. Allow the baby to feed at least every 3 hr.
Correct Answer: D
Rationale: The correct answer is D: Allow the baby to feed at least every 3 hr. This instruction is essential to ensure the newborn receives adequate nutrition and maintains a healthy breastfeeding schedule. Feeding every 3 hours helps in establishing a proper feeding routine, ensures the baby gets enough milk, stimulates milk production in the mother, and helps prevent issues like engorgement and mastitis.
Choice A is incorrect because feeding time should not be restricted to a specific duration. Choice B is incorrect as water is unnecessary for newborns who are exclusively breastfed. Choice C is incorrect as the number of wet diapers can vary and is not a reliable indicator of sufficient milk intake. Choices E, F, and G are not provided.
The nurse is assessing the client 30 min later. How should the nurse interpret the findings? For each finding, click to specify whether the finding is unrelated to the diagnosis, an indication of potential improvement, or an indication of potential worsening condition.
- A. Fundus at level of umbilicus
- B. Cloudy urine
- C. Blood pressure 80/50 mm Hg
- D. Moderate lochia rubra
- E. Thready pulse
- F. Fundus firm to palpation
Correct Answer:
Rationale: Correct Answer:
Rationale:
- Fundus at the level of the umbilicus indicates proper involution of the uterus, a sign of potential improvement.
- Cloudy urine is unrelated to the diagnosis and may indicate a urinary tract infection.
- Blood pressure of 80/50 mm Hg is an indication of potential worsening condition, indicating hypotension.
- Moderate lochia rubra is a normal finding in the postpartum period.
- Thready pulse is an indication of potential worsening condition, suggesting poor perfusion.
- Fundus firm to palpation is a normal finding indicating proper uterine contraction and involution.
A nurse is reviewing the prescriptions for a client who is pregnant and is taking digoxin. Which of the following actions should the nurse take to best evaluate the client’s medication adherence?
- A. Ask the client if they are taking the medication as prescribed.
- B. Assess the client’s kidney function.
- C. Determine the client’s apical pulse rate.
- D. Check the client’s serum medication level.
Correct Answer: D
Rationale: The correct answer is D: Check the client’s serum medication level. This is the best way to evaluate medication adherence for a client taking digoxin during pregnancy. Digoxin has a narrow therapeutic range, and monitoring the serum level helps ensure the client is taking the medication as prescribed. Option A is not as reliable as self-reporting may not be accurate. Option B, assessing kidney function, is important but not directly related to medication adherence. Option C, determining the apical pulse rate, may indicate the medication's effectiveness but does not confirm adherence. Checking the serum medication level directly assesses the actual drug concentration in the body, providing concrete evidence of adherence.