Nokea
A nurse is caring for four clients. For which of the following clients should the nurse auscultate the fetal heart rate during the prenatal visit?
- A. A client who has an ultrasound that confirms a molar pregnancy
- B. A client who has a crown-rump length of 7 weeks gestation
- C. A client who has a positive urine pregnancy test 1 week after missed menses
- D. A client who has felt quickening for the first time
Correct Answer: B
Rationale: The nurse should auscultate the fetal heart rate during the prenatal visit for the client who has a crown-rump length of 7 weeks gestation. At this stage, the fetal heart is usually visible on ultrasound, and auscultating the fetal heart rate can provide valuable information about the health and development of the fetus. It is an important part of prenatal care to monitor the fetal heart rate regularly to ensure the well-being of the baby. In the other scenarios provided:
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A client with acute respiratory failure (ARF) may present with which of the following manifestations? (Select one that doesn't apply.)
- A. Severe dyspnea
- B. Decreased level of consciousness
- C. Headache
- D. Nausea
Correct Answer: D
Rationale: In acute respiratory failure (ARF), the body is not getting enough oxygen, leading to respiratory distress. Symptoms of ARF typically include severe dyspnea (difficulty breathing), decreased level of consciousness due to hypoxia, and headache from inadequate oxygenation to the brain. Nausea is not a typical manifestation of ARF and would not be expected in this condition.
A nurse is conducting a discharge teaching for a client going home after cesarean section. Which S&S should the client be taught to report?
- A. Frequency urgency and burning on urination
- B. Feeling pelvic fullness
- C. Redness or edema of abdominal decision
- D. Mild incisional pain
Correct Answer: A
Rationale: After a cesarean section, the client should be taught to report symptoms of a urinary tract infection, such as frequency, urgency, and burning on urination. These symptoms can indicate an infection which needs prompt treatment to prevent complications. It is important for the client to report these symptoms to their healthcare provider for appropriate evaluation and management.
A nurse is admitting a client who is at 33 weeks of gestation and has preeclampsia with severe features. Which of the following actions should the nurse take?
- A. Restrict protein intake to less than 40 g/day.
- B. Initiate seizure precautions for the client.
- C. Initiate an infusion of 0.9% sodium chloride at 150 mL/hr.
- D. Encourage the client to ambulate twice per day.
Correct Answer: B
Rationale: In a client with preeclampsia with severe features at 33 weeks of gestation, initiating seizure precautions is a priority nursing action. Preeclampsia with severe features places the client at an increased risk for seizures. Therefore, the nurse should ensure that seizure precautions are in place, such as maintaining a safe environment, pad the side rails of the bed, and have emergency medications and equipment readily available. Monitoring for signs and symptoms of worsening preeclampsia and impending seizures is crucial for the client's safety and well-being.
A woman's temperature has just risen 0.4°F and will remain elevated during the remainder of her cycle. She expects to menstruate in about 2 weeks. Which of the following hormones is responsible for the change?
- A. Progesterone
- B. Follicle stimulating hormone
- C. Luteinizing hormone
- D. Estrogen
Correct Answer: D
Rationale: The hormone responsible for the increase in body temperature prior to menstruation is estrogen. Estrogen is the primary female sex hormone that plays a key role in regulating the menstrual cycle. Around the time of ovulation, estrogen levels peak, which can lead to a slight rise in body temperature. This increase in temperature is known as the "estrogenic temperature shift" and is a normal part of the menstrual cycle. The rise in body temperature indicates that ovulation has occurred and that a woman is approaching her fertile window. Estrogen also helps prepare the uterine lining for pregnancy and plays a role in many other reproductive functions.
A nurse is caring for a client who is in labor and has an epidural for pain control. Which of the following clinical ... effect of epidural anesthesia?
- A. Polyuria
- B. Hypertensi on
- C. Pruritus
- D. Dry mouth
Correct Answer: C
Rationale: Epidural anesthesia can result in some common side effects, one of which is pruritus (itching). Pruritus is a known side effect of the local anesthetics used in epidural anesthesia and is due to their effects on specialized receptors in the nervous system. Patients may experience itching, especially in the face, neck, and upper chest areas. Polyuria (increased urine output), hypertension (high blood pressure), and dry mouth are not typically associated side effects of epidural anesthesia.