Nokea
A patient is placed on bed rest at home for mild preeclampsia at 38 weeks' gestation. Which of the following must the nurse teach the patient regarding her condition?
- A. Eat a sodium-restricted diet.
- B. Check her temperature 4 times daily.
- C. Report swollen hands and face.
- D. Limit fluids to 1 liter per day.
Correct Answer: C
Rationale: Swelling in the hands and face can be a sign of worsening preeclampsia and should be reported immediately. Sodium restriction and fluid limits are not typically recommended for mild preeclampsia.
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When providing contraceptive counseling to a woman, which of the following factors should the nurse consider? Select all that apply.
- A. Age.
- B. Obstetric history.
- C. Religious beliefs.
- D. Employment.
Correct Answer: A
Rationale: Age, obstetric history, and religious beliefs are important factors to consider when providing contraceptive counseling. Employment is less relevant to contraceptive choice.
The triage nurse is interviewing a client, 19 years old, unmarried, who states, 'I felt a hard thing on the lip of my vagina this morning. It doesn’t hurt.' Which of the following questions is most important for the nurse to ask at this time?
- A. Have any of your partners ever hurt you?'
- B. Do you ever have unprotected intercourse?'
- C. Have you ever had a baby?'
- D. Do you think you may be pregnant?'
Correct Answer: B
Rationale: Unprotected intercourse increases the risk of sexually transmitted infections (STIs), which could explain the hard lump.
A patient in her third trimester of pregnancy is asking about safe travel. Which statement should the nurse provide regarding safe travel during pregnancy?
- A. Only travel by car during pregnancy.'
- B. Avoid use of the seat belt during the third trimester.'
- C. You can travel by plane until your 38th week of gestation.'
- D. If you are traveling by car stop to walk every 1 to 2 hours.'
Correct Answer: D
Rationale: The correct answer is D: "If you are traveling by car, stop to walk every 1 to 2 hours." This is the best advice because it promotes circulation and reduces the risk of blood clots during long car rides. Walking helps prevent stiffness and discomfort.
A: "Only travel by car during pregnancy" is incorrect because other modes of transportation can be safe as well.
B: "Avoid use of the seat belt during the third trimester" is incorrect as wearing a seat belt is crucial for the safety of both the mother and the baby in case of an accident.
C: "You can travel by plane until your 38th week of gestation" is incorrect as most airlines have restrictions on flying after 36 weeks due to the risk of preterm labor.
The nurse is preparing to assist with the insertion of an intrauterine pressure catheter and a fetal spiral electrode. What is required for proper placement by the practitioner? Select all that apply.
- A. Rupture of membranes
- B. Dilated cervix
- C. Vertex fetus
- D. Moderate variability
Correct Answer: A
Rationale: Correct Answer: A - Rupture of membranes
Rationale:
1. Rupture of membranes is necessary for the insertion of intrauterine pressure catheter and fetal spiral electrode.
2. It allows safe passage of the catheter and electrode into the uterus.
3. Without ruptured membranes, there is a risk of infection and difficulty in inserting the devices.
Summary:
- Choice B (Dilated cervix) is not required for the insertion of these devices.
- Choice C (Vertex fetus) is not a factor in the insertion process.
- Choice D (Moderate variability) is related to fetal heart rate monitoring, not device insertion.
The doctor has ordered a contraction stress test. The nurse should interpret which of the following as a negative test?
- A. The fetal heart remains stable in relation to 3 contractions.
- B. The uterine contractions last longer than 90 seconds.
- C. The mother reports a pain level that is less than 5 on a 10-point scale.
- D. The baby moves spontaneously 3 times in 20 minutes.
Correct Answer: A
Rationale: A negative contraction stress test indicates that the fetal heart rate remains stable during contractions, suggesting no fetal distress.