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A nurse on an antepartum unit is caring for four clients. Which of the following clients should the nurse identify as the priority?
- A. A client who has gestational diabetes and a fasting blood glucose level of 120 mg/dL (less than 95 mg/dL)
- B. A client who is at 34 weeks of gestation and reports epigastric pain
- C. A client who is at 28 weeks of gestation and has an Hgb of 10.4 g/dL (11 to 16 g/dL)
- D. A client who is at 39 weeks of gestation and reports urinary frequency and dysuria
Correct Answer: B
Rationale: The correct answer is B: A client who is at 34 weeks of gestation and reports epigastric pain. This client should be identified as the priority because epigastric pain in pregnancy can be a sign of preeclampsia, a serious condition that requires immediate attention to prevent maternal and fetal complications. Preeclampsia is characterized by high blood pressure and protein in the urine, and it can lead to seizures (eclampsia) if not managed promptly. The other clients have issues that are important but not as urgent as potential preeclampsia. Client A's blood glucose level is elevated but not critically high, Client C's hemoglobin level is slightly low but not acutely life-threatening, and Client D's symptoms of urinary frequency and dysuria are common in late pregnancy and do not indicate a medical emergency.
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A school nurse is providing teaching to an adolescent about levonorgestrel contraception. Which of the following information should the nurse include in the teaching?
- A. You should take the medication within 72 hours following unprotected sexual intercourse.
- B. You should avoid taking this medication if you are on an oral contraceptive.
- C. If you don't start your period within 5 days of taking this medication, you will need a pregnancy test.
- D. One dose of this medication will prevent you from becoming pregnant for 14 days after taking it.
Correct Answer: A
Rationale: The correct answer is A. Levonorgestrel is an emergency contraception pill effective if taken within 72 hours post unprotected sex. This is crucial information for the adolescent to prevent pregnancy. Choice B is incorrect as it does not interact with oral contraceptives. Choice C is incorrect as missing a period does not necessarily indicate pregnancy. Choice D is incorrect as it only provides immediate protection, not for 14 days.
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing. 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
- A. Place newborn skin to skin on birthing parent's chest, Encourage birthing parent to breastfeed, Obtain a prescription for arterial blood gases, Plan to initiate phototherapy, Perform neonatal abstinence system scoring.
- B. Cold stress, Acute bilirubin encephalopathy, Respiratory distress syndrome, Neonatal abstinence syndrome (NAS)
- C. Stool output, Temperature, Lung sounds, Blood glucose level, Bilirubin level
Correct Answer:
Rationale: Action to Take: A, B; Potential Condition: B; Parameter to Monitor: C, E. The correct answer is to place newborn skin to skin on birthing parent's chest (A) to promote bonding and regulate temperature, and encourage breastfeeding (B) for nutrition and immune benefits. The potential condition the client is most likely experiencing is Cold stress (B), indicated by the need for phototherapy. The nurse should monitor Temperature (C) for signs of hypothermia and Bilirubin level (E) to assess jaundice severity. These interventions and parameters address the client's most likely condition and provide comprehensive care.
A nurse is teaching about home safety with a client who is 2 days postpartum. Which of the following instructions should the nurse include in the teaching?
- A. Bathe your baby immediately after a feeding.
- B. Place a bumper pad in your baby’s crib.
- C. Put a soft mattress in your baby’s crib.
- D. Wash your baby’s face with plain water.
Correct Answer: D
Rationale: The correct answer is D: Wash your baby's face with plain water. This instruction is important to prevent skin irritation and infection in newborns. Washing the baby's face with plain water helps to keep the delicate skin clean without introducing any harsh chemicals or irritants. It is gentle and safe for the baby's sensitive skin.
Summary of why the other choices are incorrect:
A: Bathing the baby immediately after a feeding can lead to discomfort and potential issues with digestion.
B: Placing a bumper pad in the baby's crib increases the risk of suffocation and Sudden Infant Death Syndrome (SIDS).
C: Putting a soft mattress in the crib can pose a suffocation hazard and increase the risk of SIDS.
E, F, G: No additional choices provided.
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 known to cause breast tenderness as a common adverse effect due to its estrogen-like effects. This occurs because clomiphene citrate can increase estrogen levels in the body, leading to breast discomfort. Tinnitus (B), urinary frequency (C), and chills (D) are not typically associated with clomiphene citrate use. Tinnitus is more commonly linked to ototoxic medications, urinary frequency may occur with diuretics, and chills are often seen with infections or febrile illnesses. Therefore, the nurse should emphasize breast tenderness as a potential side effect of clomiphene citrate to the client.
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 as it helps to monitor the baby's heart rate in response to its movements, providing crucial information about fetal well-being. Pressing the button allows the nurse to correlate fetal movements with changes in the heart rate, helping to assess the baby's overall health and response to stimuli. Maintaining the client NPO (A) is not necessary for a nonstress test. Placing the client in a supine position (B) can decrease blood flow to the baby and is not recommended. Instructing the client to massage the abdomen (C) may artificially stimulate fetal movements, affecting the accuracy of the test results.