Nokea
A nurse is teaching about clomiphene citrate to a client who is experiencing infertility. Which of the following adverse effects should the nurse include?
- A. Breast tenderness
- B. Tinnitus
- C. Urinary frequency
- D. Chills
Correct Answer: A
Rationale: The correct answer is A: Breast tenderness. Clomiphene citrate is a medication commonly used to treat infertility by inducing ovulation. Breast tenderness is a common adverse effect due to the hormonal changes it causes in the body. This is important for the nurse to include in the teaching as it helps the client anticipate and manage this side effect. Tinnitus (B), urinary frequency (C), and chills (D) are not typically associated with clomiphene citrate use and are less likely to be relevant to discuss with the client in this context.
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A nurse is teaching a client who is at 10 weeks of gestation about nutrition during pregnancy. Which of the following statements by the client indicates an understanding of the teaching?
- A. "I should increase my protein intake to 60 grams each day."
- B. "I should drink 2 liters of water each day."
- C. "I should increase my overall daily caloric intake by 300 calories."
- D. "I should take 600 micrograms of folic acid each day."
Correct Answer: A
Rationale: The correct answer is A because protein is essential for fetal development and increasing protein intake to 60 grams per day is recommended during pregnancy for optimal growth. Adequate protein intake helps in the formation of new tissues and cells.
Choice B is incorrect because while staying hydrated is important during pregnancy, the specific amount of 2 liters per day is not a standard recommendation and may vary depending on individual needs.
Choice C is incorrect as increasing overall daily caloric intake by 300 calories is a general guideline, not specific to the client's gestational age.
Choice D is incorrect as while folic acid is crucial during pregnancy to prevent birth defects, the recommended daily intake is usually 400-800 micrograms, so 600 micrograms is within the range but not the best answer.
A nurse is assessing a client who gave birth vaginally 12 hr ago and palpates their uterus to the right above the umbilicus. Which of the following interventions should the nurse perform?
- A. Reassess the client in 2 hr.
- B. Administer simethicone.
- C. Assist the client to empty their bladder.
- D. Instruct the client to lie on their right side.
Correct Answer: C
Rationale: The correct answer is C: Assist the client to empty their bladder. This is the correct intervention because a uterus palpable to the right above the umbilicus indicates a full bladder causing displacement of the uterus. Emptying the bladder will allow the uterus to return to the midline. Choice A is incorrect as the immediate issue is a full bladder, not requiring a wait of 2 hours. Choice B (administer simethicone) is incorrect as this medication is for gas relief and not relevant in this scenario. Choice D (instruct the client to lie on their right side) is incorrect as it does not address the underlying problem of a full bladder.
A nurse is planning care for a client who is 1 hr postpartum and has peripartum cardiomyopathy. Which of the following actions should the nurse plan to take?
- A. Obtain a prescription for misoprostol.
- B. Assess blood pressure twice daily.
- C. Restrict daily oral fluid intake.
- D. Administer an IV bolus of lactated Ringer's.
Correct Answer: B
Rationale: The correct answer is B: Assess blood pressure twice daily. In peripartum cardiomyopathy, monitoring blood pressure is crucial to detect any signs of worsening cardiac function or complications. Regular assessment can help identify hypertension or hypotension, which are common in this condition. Misoprostol (A) is not indicated for peripartum cardiomyopathy. Restricting oral fluid intake (C) can be harmful as adequate hydration is important postpartum. Administering an IV bolus of lactated Ringer's (D) may not be necessary unless specifically ordered by the healthcare provider based on the client's condition.
Which of the following is a potential indication for induction of labor?
- A. Preeclampsia
- B. Gestational diabetes
- C. Fetal macrosomia
- D. All of the above
Correct Answer: A
Rationale: Preeclampsia is a common indication for the induction of labor.
A nurse is caring for a client who is at 38 weeks of gestation. Which of the following actions should the nurse take prior to applying an external transducer for fetal monitoring?
- A. Determine progression of dilatation and effacement.
- B. Perform Leopold maneuvers.
- C. Complete a sterile speculum exam.
- D. Prepare a Nitrazine paper test.
Correct Answer: B
Rationale: Performing Leopold maneuvers helps the nurse determine the fetal position and presentation, which is essential for accurate placement of the external transducer.