Nokea
A patient had unprotected sex yesterday. She is interested in emergency contraception. The nurse knows that the patient has how long to take the medication for it to be effective?
- A. 24 hr
- B. 48 hr
- C. 3 days
- D. 5 days
Correct Answer: C
Rationale: Emergency contraception is most effective if taken within 3 days after unprotected sex. The sooner it is taken, the more effective it is. Choice A and B are incorrect because they are too short a time window for emergency contraception to be effective. Choice D is also incorrect because most emergency contraceptive pills are not effective after 5 days.
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The nurse is educating a client about signs of labor. Which statement indicates understanding?
- A. False labor contractions cause cervical changes.
- B. True labor contractions decrease with activity.
- C. True labor contractions become stronger and more regular.
- D. False labor contractions are felt in the back.
Correct Answer: C
Rationale: True labor is characterized by regular, strong contractions that lead to cervical changes.
Which action is the most appropriate nursing measure when a baby has an unexpected defect at birth?
- A. Remove the baby from the delivery area immediately.
- B. Inform the parents immediately that something is wrong.
- C. Tell the parents that the baby has to go to the nursery immediately.
- D. Explain the defect and show the baby to the parents as soon as possible.
Correct Answer: D
Rationale: When a baby is born with an unexpected defect, it is crucial for the nursing staff to explain the defect to the parents and show the baby to them as soon as possible. This approach allows for open communication, transparency, and the opportunity for the parents to start processing the situation emotionally. By involving the parents and keeping them informed, trust and understanding can be established between the healthcare providers and the family, ultimately fostering a supportive environment for everyone involved in the care of the baby. It is essential to approach the situation with empathy and sensitivity while providing the necessary information to the parents.
A nurse is caring for a 2-day-old newborn who was born at 35 weeks of gestation. Which of the following actions should the nurse the nurse takes? (Click on the "Exhibit" Button for additional information about the newborn. There are three tabs that contain separate categories of date.)
- A. Administer nitric oxide inhalation therapy to the newborn
- B. Insert an orogastric decompression tube with low wall suction.
- C. Provide the newborn with an iron-rich formula containing vitamin B12 every 2 hr.
- D. Measure the abdominal circumference at the level of the newborn's umbilicus every 2 hr.
Correct Answer: D
Rationale: Since the newborn was born at 35 weeks of gestation, with a birth weight of 2.3 kg and exhibiting clinical signs of hypoglycemia, one of the key priorities in caring for this newborn is monitoring for complications related to prematurity. Measuring the abdominal circumference at the level of the newborn's umbilicus every 2 hours is important in assessing for signs of abdominal distention, which could indicate necrotizing enterocolitis (NEC), a serious condition commonly seen in premature infants. Early detection through frequent abdominal circumference measurements can aid in timely intervention and management to prevent significant complications. Administering nitric oxide inhalation therapy, inserting an orogastric decompression tube with low wall suction, and providing iron-rich formula containing vitamin B12 every 2 hours are not indicated based on the information provided in the exhibit.
A nurse is caring for a client who has preeclampsia and is being treated with magnesium sulfate IV. The client's respiratory rate is 10/min and deep-tendon reflexes are absent. Which of the following actions should the nurse take?
- A. Discontinue the medication infusion.
- B. Prepare for an emergency cesarean birth.
- C. Assess maternal blood glucose.
- D. Place the client in Trendelenburg position.
Correct Answer: A
Rationale: The most appropriate action for the nurse to take in this situation is to discontinue the medication infusion. The client is showing signs of magnesium sulfate toxicity, which can include respiratory depression (low respiratory rate) and absent deep-tendon reflexes. These are early signs of magnesium toxicity, and prompt action is needed to prevent further complications. Discontinuing the medication infusion will help reduce the risk of magnesium toxicity worsening. The other options are not appropriate in this situation as they do not address the immediate concern of magnesium toxicity.
is a vitamin supplement prescribed for clients who have hyperemesis gravidarum.
- A. INCORRECT: Ferrous sulfate is a medication used in the treatment of iron deficiency anemia.
- B. CORRECT: Calcium gluconate is the antidote for magnesium sulfate. the baby is inside. What is the nurse9s best response?
- C. "Your baby's umbilical cord is surrounded by connective tissue called Wharton jelly, which prevents compression of the blood vessels and ensures continued nourishment of your baby."
Correct Answer: B
Rationale: Calcium gluconate is indeed the antidote for magnesium sulfate toxicity. In cases where a pregnant client is receiving magnesium sulfate for conditions like preeclampsia, it is important to have calcium gluconate readily available in case of magnesium toxicity. This is a crucial intervention to prevent any adverse effects on both the mother and the baby. So, the nurse should ensure that calcium gluconate is available and be prepared to administer it if needed.