Nokea
A nurse is providing dietary teaching to a client who has hyperemesis gravidarum. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will eat foods that taste good instead of balancing my meals.
- B. I will avoid having a snack before I go to bed each night.
- C. I will have a cup of hot tea with each meal.
- D. I will eliminate products that contain dairy from my diet.
Correct Answer: D
Rationale: Eliminating dairy products may help reduce nausea and vomiting in clients with hyperemesis gravidarum, as dairy can sometimes exacerbate these symptoms.
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For each finding, click to specity if the finding increases the client's risk for uterine atony or infection.
- A. Prenatal anemia
- B. High parity
- C. Prolonged rupture of membranes
- D. Cesarean birth
- E. Polyhydramnios
Correct Answer:
Rationale:
A nurse is assessing the fontanels of an 8-month-old infant. Which of the following findings should the nurse recognize as an expected finding?
- A. The posterior fontanel is open.
- B. The anterior fontanel is open
- C. Both fontanels are the same size.
- D. Both fontanels show molding.
Correct Answer: B
Rationale: The anterior fontanel typically remains open until around 18 months of age, while the posterior fontanel usually closes by 2-3 months. Molding is not an expected finding at this age.
A nurse is preparing to assess fetal heart tones for a client who is at 12 weeks of gestation. Which of the following actions should the nurse take?
- A. Place the client in a side-lying position prior to assessing the fetal heart rate
- B. Measure the fundal height to determine the placement of the ultrasound stethoscope.
- C. Position the ultrasound stethoscope above the symphysis pubis to assess the fetal heart rate.
- D. Perform Leopold maneuvers prior to auscultating the fetal heart rate.
Correct Answer: C
Rationale: At 12 weeks of gestation, the fetal heart rate is best assessed by placing the ultrasound stethoscope above the symphysis pubis, where the uterus is located.
A nurse is caring for a client who is hypotensive following the administration of epidural anesthesia. Which of the following actions should the nurse take?
- A. Turn the client to a side-lying position.
- B. Apply oxygen at 2 L/min via nasal cannula.
- C. Massage the client’s fundus.
- D. Assist the client to empty their bladder.
Correct Answer: A
Rationale: The correct answer is A: Turn the client to a side-lying position. This helps to improve blood flow and circulation, which can help increase blood pressure in a hypotensive client. Placing the client on their side also helps prevent potential complications such as supine hypotension syndrome.
Choice B is incorrect because administering oxygen may not directly address the underlying cause of hypotension in this situation.
Choice C is incorrect as massaging the fundus is typically done to assess postpartum bleeding in women who have recently given birth, not for hypotension following epidural anesthesia.
Choice D is incorrect because while emptying the bladder can help in some cases of hypotension, it may not be the most immediate or appropriate action in this scenario.
A nurse is caring for a client who is at 20 weeks of gestation and has trichomoniasis. Which of the following findings should the nurse expect?
- A. Thick, white vaginal discharge
- B. Urinary frequency
- C. Vulva lesions
- D. Malodorous discharge
Correct Answer: D
Rationale: The correct answer is D: Malodorous discharge. Trichomoniasis is a sexually transmitted infection caused by a parasite, resulting in a foul-smelling, greenish-yellow vaginal discharge. This characteristic discharge is due to the infection and inflammation of the vaginal mucosa. Option A (Thick, white vaginal discharge) is more indicative of a yeast infection, while option B (Urinary frequency) is not specific to trichomoniasis. Option C (Vulva lesions) is not a common symptom of trichomoniasis. Overall, the malodorous discharge is the key finding in diagnosing trichomoniasis at 20 weeks of gestation.