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. This action is essential during a nonstress test to track fetal movement and heart rate patterns. By pressing the button each time fetal movement is felt, the nurse can correlate these movements with any changes in the fetal heart rate, providing valuable information about fetal well-being. Maintaining the client NPO (A) is not necessary for a nonstress test. Placing the client in a supine position (B) can reduce blood flow to the fetus and is not recommended. Instructing the client to massage the abdomen (C) may lead to inaccurate test results by artificially stimulating fetal movements.
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Which of the following nursing actions should the nurse plan to take? For each potential nursing action, click to specify it the intervention is indicated or contraindicated for the client.
- A. Insert a large bore intravenous catheter.
- B. Assess cervical dilation.
- C. Weigh perineal pads.
- D. Administer methotrexate.
Correct Answer: A, C
Rationale: [1, 0, 1], [0, 1, 0], [0, 0, 0], [0, 0, 1]
Inserting a large bore IV catheter is indicated for rapid fluid resuscitation. Weighing perineal pads helps monitor postpartum hemorrhage. Assessing cervical dilation and administering methotrexate are not appropriate in this scenario.
Which of the following conditions should the nurse identify as being consistent with the adolescent's assessment findings? For each finding click to specify if the assessment findings are consistent with trichomoniasis, gonorrhea, or candidiasis. Each finding may support more than one disease process.
- A. Abdominal pain.
- B. Greenish discharge.
- C. Diabetes.
- D. Pain on urination.
- E. Absence of condom.
Correct Answer: B, D
Rationale: To determine the correct answer, we look at the assessment findings. For "Greenish discharge," this is consistent with both trichomoniasis and gonorrhea. Trichomoniasis typically presents with a frothy, yellow-green discharge, while gonorrhea can cause a greenish or yellow discharge. "Pain on urination" is also a common symptom of both gonorrhea and trichomoniasis. Therefore, the correct answer is B, D. Abdominal pain is not specific to any of the mentioned conditions and is not a defining symptom. Diabetes is not directly related to the assessment findings provided. The absence of a condom is not a symptom but rather a risk factor for sexually transmitted infections.
A nurse in a prenatal clinic is assessing a group of clients. Which of the following clients should the nurse see first?
- A. A client who is at 11 weeks of gestation and reports abdominal cramping.
- B. A client who is at 15 weeks of gestation and reports tingling and numbness in right hand.
- C. A client who is at 20 weeks of gestation and reports constipation for the past 4 days.
- D. A client who is at 8 weeks of gestation and reports having three bloody noses in the past week.
Correct Answer: A
Rationale: The correct answer is A. Abdominal cramping in early pregnancy could be a sign of an ectopic pregnancy or miscarriage, both of which are urgent and potentially life-threatening conditions. The nurse should prioritize assessing this client to rule out any serious complications.
Choice B is not as urgent as choice A because tingling and numbness in the hand are likely due to musculoskeletal or nerve compression issues, which are not immediately life-threatening.
Choice C, constipation, is a common issue in pregnancy and is not typically considered an urgent concern unless accompanied by severe symptoms like abdominal pain or bleeding.
Choice D, frequent bloody noses, is not typically an urgent concern in early pregnancy unless it is accompanied by other severe symptoms like dizziness or excessive bleeding.
In summary, the nurse should prioritize assessing the client experiencing abdominal cramping at 11 weeks of gestation due to the potential seriousness of this symptom in early pregnancy.
A nurse is caring for a client who is to receive oxytocin to augment their labor. Which of the following findings contraindicates the initiation of the oxytocin infusion and should be reported to the provider?
- A. Late decelerations.
- B. Moderate variability of the FHR.
- C. Cessation of uterine dilation.
- D. Prolonged active phase of labor.
Correct Answer: A
Rationale: The correct answer is A: Late decelerations. Late decelerations indicate uteroplacental insufficiency, meaning the baby is not getting enough oxygen during contractions. Administering oxytocin, which can further stress the baby by increasing contractions, can worsen the situation. Late decelerations are a sign of fetal distress and require immediate intervention.
B: Moderate variability of the FHR is a normal finding and does not contraindicate the initiation of oxytocin.
C: Cessation of uterine dilation would suggest a potential issue with labor progress but does not directly contraindicate oxytocin.
D: Prolonged active phase of labor may warrant oxytocin to augment contractions but is not a contraindication itself.
A nurse is assessing a client who is at 30 weeks of gestation during a routine prenatal visit. Which of the following findings should the nurse report to the provider?
- A. Swelling of the face.
- B. Varicose veins in the calves.
- C. Nonpitting 1+ ankle edema.
- D. Hyperpigmentation of the cheeks.
Correct Answer: A
Rationale: The correct answer is A: Swelling of the face. Facial swelling in pregnancy could be a sign of preeclampsia, a serious condition characterized by high blood pressure and protein in the urine. This requires immediate medical attention to prevent complications for both the mother and the baby. Varicose veins in the calves (B) are common in pregnancy but do not pose an immediate threat. Nonpitting 1+ ankle edema (C) is a common finding in pregnancy and typically not concerning unless it worsens. Hyperpigmentation of the cheeks (D) is also a common occurrence during pregnancy known as "the mask of pregnancy" and is not a cause for alarm.