Nokea
A pregnant client mentions in her history that she changes the cat's litter box daily. Which test should the nurse anticipate the healthcare provider to prescribe?
- A. Biophysical profile
- B. Fern test
- C. Amniocentesis
- D. TORCH screening
Correct Answer: D
Rationale: The correct answer is D, TORCH screening. TORCH screening is done to detect infections such as toxoplasmosis, which can be contracted from handling cat litter and is harmful during pregnancy. Biophysical profile (choice A) is a prenatal ultrasound evaluation. Fern test (choice B) is used to assess for amniotic fluid leakage. Amniocentesis (choice C) involves taking a sample of amniotic fluid to test for genetic abnormalities and certain infections, not specifically related to toxoplasmosis from cat litter.
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A client at 38 weeks of gestation has a prescription for intravaginal misoprostol. Which of the following statements should the nurse make?
- A. "You will need to stay in a side-lying position for 30 minutes after each dose."
- B. "You will receive an IV infusion of oxytocin 1 hour after your last dose."
- C. "You will receive a magnesium supplement immediately following therapy."
- D. "You will need to have a full bladder before the therapy begins."
Correct Answer: A
Rationale: The correct answer is A. Instructing the client to stay in a side-lying position after receiving misoprostol intravaginally is essential. This position helps keep the medication in place, allowing for better absorption. Choice B is incorrect because oxytocin administration is not typically indicated after misoprostol use. Choice C is incorrect as magnesium supplementation is not part of the standard protocol for misoprostol administration. Choice D is incorrect as having a full bladder is not necessary before initiating misoprostol therapy.
A client who is 5 days postpartum is being taught about signs of effective breastfeeding. Which information should the nurse include in the teaching?
- A. Feeling a tugging sensation when the baby is sucking
- B. Expecting the baby to have two to three wet diapers in a 24-hour period
- C. The baby's urine should appear dark and concentrated
- D. The breast should stay firm after the baby breastfeeds
Correct Answer: A
Rationale: Feeling a tugging sensation while the baby is sucking indicates an effective latch and milk transfer during breastfeeding. This sensation means that the baby is effectively drawing milk from the breast. Choice B is incorrect because infants should ideally have six to eight wet diapers in a 24-hour period to show adequate hydration. Choice C is incorrect as a dark and concentrated urine may indicate dehydration, which is not a sign of effective breastfeeding. Choice D is incorrect as the breast should soften after the baby breastfeeds, indicating that the baby has effectively emptied the breast of milk.
A client at 34 weeks gestation comes to the birthing center complaining of vaginal bleeding that began one hour ago. The nurse's assessment reveals approximately 30ML of bright red vaginal bleeding, fetal heart rate of 130 - 140 beats per minute, no contractions, and no complaints of pain. What is the most likely cause of this client's bleeding?
- A. Abruptio Placenta
- B. Placenta Previa
- C. Normal bloody show indicating induction of labor
- D. A ruptured blood vessel in the vaginal vault
Correct Answer: B
Rationale: Placenta previa, a condition where the placenta covers the cervix, can cause painless, bright red vaginal bleeding in the third trimester. In this scenario, the absence of contractions and pain, along with the presence of significant bright red bleeding, is more indicative of placenta previa rather than abruptio placenta or a ruptured vessel. A normal bloody show typically occurs closer to the onset of labor and is not associated with the amount of bleeding described in the question.
Which of the following statements is true about Tay-Sachs disease?
- A. It is most commonly found among children in Jewish families of Eastern European background.
- B. Children who have this disease suffer from excessive production of mucus in the lungs and pancreas.
- C. It is most commonly found among children in Asian American families.
- D. Children who have this disease suffer from muscular dystrophy characterized by a weakening of the muscles.
Correct Answer: A
Rationale: The correct answer is A. Tay-Sachs disease is most commonly found among Jewish families of Eastern European descent. It is a fatal genetic disorder that affects the nervous system. Choice B is incorrect because Tay-Sachs disease does not involve excessive mucus production in the lungs and pancreas. Choice C is incorrect as it states that Tay-Sachs disease is most commonly found among Asian American families, which is inaccurate. Choice D is also incorrect because Tay-Sachs disease does not cause muscular dystrophy characterized by weakening of the muscles.
A healthcare professional is planning care for a full-term newborn who is receiving phototherapy. Which of the following actions should the healthcare professional include in the plan of care?
- A. Dress the newborn in lightweight clothing.
- B. Avoid using lotion or ointment on the newborn's skin.
- C. Keep the newborn supine throughout treatment.
- D. Measure the newborn's temperature every 8 hours.
Correct Answer: B
Rationale: When a newborn is receiving phototherapy, it is important to avoid using lotions or ointments on their skin as these products can lead to skin irritation and burns under the phototherapy lights. Dressing the newborn in lightweight clothing helps ensure proper exposure to the phototherapy lights. Keeping the newborn supine during treatment helps maximize exposure to the light. However, the key consideration in this scenario is to prevent skin irritation and burns by avoiding lotions or ointments.