Nokea
A nurse is caring for several clients. The nurse should recognize that it is safe to administer tocolytic therapy to which of the following clients?
- A. A client who is experiencing fetal death at 32 weeks of gestation
- B. A client who is experiencing preterm labor at 26 weeks of gestation
- C. A client who is experiencing Braxton-Hicks contractions at 36 weeks of gestation
- D. A client who has a post-term pregnancy at 42 weeks of gestation
Correct Answer: B
Rationale: Tocolytic therapy is a medication given to delay preterm labor and prolong the pregnancy. It is safe and appropriate to administer tocolytic therapy to a client who is experiencing preterm labor at 26 weeks of gestation (option B) to help delay delivery and give time for other interventions to be initiated, such as administration of corticosteroids for fetal lung maturation and transfer to a facility with a NICU if necessary. The goal is to prevent premature birth and its associated complications.
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A nurse is caring for a person who is blind. What intervention could the nurse implement to deliver culturally responsive care?
- A. Ask family members to leave the room for the discussion of care.
- B. Be aware of how the person is addressed.
- C. Introduce herself with her name and credentials upon entering the room.
- D. Leave education material in Braille on the table across the room from the bed.
Correct Answer: C
Rationale: Introducing oneself clearly helps build trust and ensures the patient knows who is providing care.
What physical findings would the nurse expect in a bulimic client?
- A. Mastoiditis.
- B. Hirsutism.
- C. Gynecomastia.
- D. Esophagitis.
Correct Answer: D
Rationale: Repeated vomiting damages the esophagus.
How would the nurse best analyze the results from a patient sonogram that shows the fetal shoulder is the presenting part? What position?
- A. Bridge transverse
- B. Cephalic presentation
- C. Breech presentation
- D. Vertex presentation
Correct Answer: A
Rationale: When the sonogram shows the fetal shoulder as the presenting part, it indicates a bridge transverse position. This position means that the baby is lying sideways in the uterus, with one shoulder presenting first. It is essential for the nurse to recognize this position as it may impact the mode of delivery and require additional monitoring to ensure the safe delivery of the baby. Through proper analysis and understanding of the sonogram results, healthcare providers can make informed decisions and provide appropriate care for both the mother and the baby.
A nurse is assessing a client who is at 27 weeks of gestation and has preeclampsia. Which of the following findings should the nurse report to the provider?
- A. Urine protein concentration 200 mg/ 24 hr.
- B. Creatinine 0.8 mg/ Dl
- C. Hemoglobin 14.8 g/ dL
- D. Platelet Count 60.000/ mm3
Correct Answer: D
Rationale: A platelet count of 60,000/mm3 is significantly low and can be indicative of thrombocytopenia, a potential complication of preeclampsia known as HELLP syndrome (Hemolysis, Elevated Liver enzymes, and Low Platelet count). Thrombocytopenia increases the risk of bleeding complications during pregnancy and delivery, requiring prompt evaluation and management by the healthcare provider. The nurse should report this finding immediately to prevent any adverse outcomes for the client and baby.
The nurse teaches a new mother that neonatal weight loss in the first 3 days of life is most often the result of:
- A. Allergy to formula
- B. a hypoglycemic response
- C. Inadequate breast or formula feeding
- D. Excretion of fluid via lungs, urinary bladder and bowels.
Correct Answer: D
Rationale: Fluid loss is the primary cause of early weight loss.