Nokea
A nurse is planning care for a client who is to undergo a nonstress test. Which of the following actions should the nurse include in the plan of care?
- A. Maintain the client NPO throughout the procedure.
- B. Place the client in a supine position.
- C. Instruct the client to massage the abdomen to stimulate fetal movement.
- D. Instruct the client to press the provided button each time fetal movement is detected.
Correct Answer: D
Rationale: The correct answer is D: Instruct the client to press the provided button each time fetal movement is detected. During a nonstress test, the client is monitored for fetal heart rate accelerations in response to fetal movement. Instructing the client to press the button each time fetal movement is detected helps correlate fetal heart rate changes with fetal activity. This is crucial in assessing the well-being of the fetus.
A, B, and C are incorrect choices because maintaining the client NPO, placing the client in a supine position, and instructing the client to massage the abdomen are not relevant or necessary for a nonstress test. Option D is the best choice as it directly assists in monitoring fetal well-being during the test.
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Which of the following is a potential cause of female infertility?
- A. Polycystic ovary syndrome (PCOS)
- B. Endometriosis
- C. Pelvic inflammatory disease (PID)
- D. All of the above
Correct Answer: D
Rationale: PCOS endometriosis and PID are all common causes of female infertility. These conditions can disrupt normal reproductive function making conception difficult.
A nurse in a family planning clinic is caring for a client who requests an oral contraceptive. Which of the following findings in the client’s history should the nurse recognize as a contraindication to oral contraceptives? (Select all that apply.)
- A. Cholecystitis
- B. Hypertension
- C. Human papillomavirus
- D. Migraine headaches
Correct Answer: A, B, D
Rationale: The correct answer is A, B, D. Cholecystitis is a contraindication due to increased risk of gallbladder disease. Hypertension is a contraindication as estrogen in oral contraceptives can elevate blood pressure. Migraine headaches with aura are contraindicated due to increased risk of stroke. Human papillomavirus is not a contraindication. It's important to consider individual health factors for each client when prescribing oral contraceptives.
Which of the following is a professional standard for nursing practice in maternal and newborn healthcare?
- A. Collaboration with patients and families
- B. Continuity of care
- C. Cultural competence
- D. All of the above
Correct Answer: D
Rationale: The correct answer is D: All of the above. Collaboration with patients and families enhances patient-centered care, continuity of care ensures seamless transitions in healthcare delivery, and cultural competence promotes understanding and respect for diverse beliefs and practices. These three standards are crucial in maternal and newborn healthcare to ensure holistic, safe, and effective care. Choosing any single option would overlook the importance of the other standards, leading to potential gaps in care delivery. Therefore, selecting all of the above ensures comprehensive adherence to professional standards in nursing practice for maternal and newborn healthcare.
A nurse is performing a routine assessment on a client who is at 18 weeks of gestation. Which of the following findings should the nurse expect?
- A. Deep tendon reflexes 4+.
- B. Fundal height 14 cm.
- C. Blood pressure 142/94 mm Hg.
- D. FHR 152/min.
Correct Answer: D
Rationale: A fetal heart rate (FHR) of 152/min is within the normal range of 110 to 160 beats per minute for a fetus at 18 weeks of gestation.
A nurse is teaching a client who has pregestational type 1 diabetes mellitus about management during pregnancy. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will need to increase my insulin doses during the first trimester.
- B. I should engage in moderate exercise for 30 minutes if my blood glucose is 250 or greater.
- C. I will continue taking my insulin if I experience nausea and vomiting.
- D. I will ensure that my bedtime snack is high in refined sugar.
Correct Answer: C
Rationale: Continuing to take insulin as prescribed, even when experiencing nausea and vomiting, is essential for maintaining blood glucose control during pregnancy.