Nokea
A nurse is teaching a prenatal class regarding false labor. Which of the following information should the nurse include?
- A. your contraction will become more intense when walking
- B. you will have dilation and effacement of the cervix
- C. You will have bloody show
- D. Your contraction will become temporally regular
Correct Answer: A
Rationale: The correct answer is A: your contractions will become more intense when walking. This is because false labor contractions typically decrease in intensity or stop completely when the individual changes positions or engages in physical activity. This is a key characteristic that helps differentiate false labor from true labor. Choices B, C, and D are incorrect as they are more indicative of true labor, where there is cervical dilation, effacement, bloody show, and regular contractions. It is important for the nurse to emphasize this distinction to ensure pregnant individuals can recognize the signs of true labor and seek appropriate care.
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A nurse 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, typically presenting with a foul-smelling, greenish-yellow vaginal discharge. This discharge is a hallmark symptom of trichomoniasis due to inflammation and infection of the vaginal mucosa. Other choices are incorrect because: A) Thick, White Vaginal Discharge is more indicative of a yeast infection; B) Urinary Frequency is not a common symptom of trichomoniasis; C) Vulva Lesions are not typically associated with trichomoniasis at 20 weeks of gestation.
A nurse on an antepartum unit is reviewing the medical records for four clients. Which of the following clients should the nurse assess first?
- A. A client who has diabetes mellitus and an HbA1c of 5.8%
- B. A client who has preeclampsia and a creatinine level of 1.1 mg/ dL
- C. A client who has hyperemesis gravidarum and a sodium level of 110 mEq/L
- D. A client who has placenta previa and a hematocrit of 36%
Correct Answer: C
Rationale: The correct answer is C. The nurse should assess the client with hyperemesis gravidarum and a sodium level of 110 mEq/L first. This client is at risk for severe dehydration and electrolyte imbalance, which can lead to serious complications such as metabolic acidosis or organ dysfunction. Prompt assessment and intervention are crucial to stabilize the client's condition.
Choice A is not the priority as a client with diabetes mellitus and an HbA1c of 5.8% is within the target range indicating good glycemic control. Choice B, a client with preeclampsia and a creatinine level of 1.1 mg/dL, requires monitoring but is not as urgent as the client with hyperemesis gravidarum. Choice D, a client with placenta previa and a hematocrit of 36%, also needs monitoring but is not as urgently concerning as electrolyte imbalance.
A nurse is using Nagele's rule to calculate the expected delivery date of a client who reports the first day of the last menstrual cycle was July 28th. Which of the following dates should the nurse document as the client's expected delivery date?
- A. April 21st
- B. April 4th
- C. May 5th
- D. May 21st
Correct Answer: C
Rationale: The correct answer is C: May 5th. Nagele's rule is used to estimate the expected delivery date by adding 7 days to the first day of the last menstrual cycle, subtracting 3 months, and then adding 1 year. In this case, the first day of the last menstrual cycle was July 28th. Adding 7 days gives August 4th. Subtracting 3 months gives May 4th. Adding 1 year gives May 4th of the next year. Since May 4th falls on a Sunday, the expected delivery date is adjusted to the following day, May 5th. Choice A, B, and D are incorrect because they do not follow the correct calculations of Nagele's rule.
A nurse is caring for a newborn who is 6 hr old and has a bedside glucometer reading of 65 mg/ dL. The newborn’s mother has type 2 diabetes mellitus. Which of the following actions should the nurse take?
- A. Obtain a blood sample for a serum glucose level
- B. Feed the newborn immediately
- C. Administer 50 mL of dextrose solution IV
- D. Reassess the blood glucose level prior to the next feeding
Correct Answer: B
Rationale: The correct answer is B: Feed the newborn immediately. In this scenario, the newborn's low blood glucose level may be due to inadequate glycogen stores from the mother's diabetes. Feeding the newborn will help increase their blood glucose levels naturally. Other choices are incorrect because: A: Obtaining a blood sample for a serum glucose level delays immediate action. C: Administering dextrose solution IV is an invasive intervention that should be reserved for severe cases. D: Reassessing the blood glucose level is important but should not delay feeding in this critical situation. E, F, G: No information given.
The nurse is teaching a client and her partner about the technique of counter pressure during labor. Which of the following statements by the nurse is appropriate?
- A. Your partner will apply upward pressure on your lower abdomen between contractions
- B. Your partner will apply continuous firm pressure between your thumb and index finger
- C. Your partner will apply pressure to the top of your uterus during contractions
- D. Your partner will apply steady pressure with a tennis ball to your lower back
Correct Answer: D
Rationale: The correct answer is D because counter pressure is typically applied to the lower back to help alleviate back pain during labor contractions. This technique can help relieve discomfort by stimulating pressure receptors and distracting from the pain of contractions. Choice A is incorrect as upward pressure on the lower abdomen is not the standard technique for counter pressure. Choice B is incorrect as applying pressure between the thumb and index finger is not relevant to counter pressure. Choice C is incorrect as pressure should be applied to the lower back, not the top of the uterus, during contractions.