Nokea
A nurse is caring for a client who is in preterm labor at 32 weeks of gestation. The client asks the nurse, "Will my baby be okay?" Which of the following responses should the nurse offer?
- A. "You must be feeling scared and powerless."
- B. "Everyone worries about her baby when she's in labor."
- C. "Your pregnancy is advanced so your baby should be fine."
- D. "We have a neonatal unit here that's equipped to handle emergencies."
Correct Answer: D
Rationale: The most appropriate response for the nurse to offer in this situation is to inform the client that there is a neonatal unit equipped to handle emergencies. This response provides the client with reassurance that if there are any complications with the baby being born prematurely, there is a specialized unit available to provide the necessary care. It addresses the client's concern about the well-being of her baby while also offering a practical solution in case of any emergencies.
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A client at 12 weeks' gestation asks why folic acid is important during pregnancy. What is the nurse's best response?
- A. It helps prevent gestational diabetes.
- B. It promotes fetal brain development.
- C. It reduces the risk of neural tube defects.
- D. It increases maternal energy levels.
Correct Answer: C
Rationale: Folic acid is essential during early pregnancy to reduce the risk of neural tube defects like spina bifida.
The nurse is monitoring a pregnant client undergoing a nonstress test. What is a reassuring finding?
- A. Two accelerations in 20 minutes.
- B. Baseline fetal heart rate of 170 beats/minute.
- C. Decreased fetal movement.
- D. Variable decelerations.
Correct Answer: A
Rationale: Two accelerations within 20 minutes indicate a reactive and reassuring nonstress test result.
Which client would be at greatest risk for developing
- A. Thick breast cancer?
- B. Wet/slippery with egg white consistency
- C. Client who had her first baby at the age of 24
- D. Client who did not breastfeed
Correct Answer: D
Rationale: Not breastfeeding has been identified as a risk factor for developing breast cancer. Breastfeeding has been shown to have a protective effect against breast cancer due to its impact on hormonal levels and breast tissue changes that occur during lactation. Therefore, compared to other options, the client who did not breastfeed would be at greater risk for developing breast cancer.
A patient calls the clinic Monday morning. She had condomless sex Friday night and is interested in emergency contraception. What should the nurse tell this patient?
- A. Emergency contraception pills are very effective for medically induced abortions early in pregnancy.
- B. If she is not midcycle when she had sex, she does not need emergency contraception.
- C. It is too late for her to use emergency contraceptive pills, but she can come in for placement of a copper IUD.
- D. She can use emergency contraceptive pills, even if she has had other condomless sex since the Friday night event.
Correct Answer: D
Rationale: The correct advice for the patient in this scenario is to inform her that she can still use emergency contraceptive pills, even if she has had other condomless sex since the Friday night event. Emergency contraceptive pills are most effective when taken as soon as possible after unprotected sex, but they can still be used within a certain window of time depending on the type of pill used. It is important to inform the patient that she can take emergency contraception in this situation to reduce the risk of an unintended pregnancy.
A 17-year-old patient receives emergency contraception in a clinic. What is the priority nursing education for this patient at this time?
- A. The need for further contraception because the emergency contraception is only temporary
- B. The need to protect herself from STIs
- C. The need to come back in for a pelvic examination 1 week after taking the medication
- D. The need to drink plenty of fluids while on this medication
Correct Answer: A
Rationale: The patient should be informed that emergency contraception is a temporary measure and they need a long-term contraceptive plan. Choice B, while important for overall sexual health, is not the priority immediately after administering emergency contraception. Choice C is not necessary unless there are complications or a follow-up consultation is needed. Choice D about drinking fluids is unnecessary and not specific to the effectiveness of emergency contraception.