Nokea
A pregnant woman is to undergo an invasive procedure to evaluate the status of her fetus. To ensure informed consent, which action would be the priority responsibility of the nurse providing care to this woman?
- A. Asking relevant questions to determine the client's understanding
- B. Providing a detailed description of the risks and benefits of the procedure
- C. Explaining the exact steps that will occur during the procedure
- D. Offering suggestions for alternative options for treatment
Correct Answer: A
Rationale: The nurse's responsibilities related to informed consent include: Ensuring the consent form is completed with signatures from the client; serving as a witness to the signature process; and determining whether the client understands what she is signing by asking her pertinent questions.
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Which of the following actions is appropriate for the nurse to take regarding a 9-year-old girl diagnosed with gonorrhea?
- A. Notify the physician so the child can be admitted to the hospital.
- B. Discuss with the girl the need to stop future sexual encounters.
- C. Question the mother about her daughter's menstrual history.
- D. Report the girl's medical findings to child protective services.
Correct Answer: D
Rationale: Gonorrhea in a 9-year-old girl is highly suggestive of sexual abuse, which requires reporting to child protective services.
A patient's newborn is neurologically impaired. The most important nursing action should be:
- A. Assist the patient and her family with the grieving process.
- B. Perform neurological assessments of the newborn every four hours.
- C. Arrange for social services to discuss possible placement of the newborn
- D. Obtain an order for an antidepressant to help the patient cope with the depressing news.
Correct Answer: A
Rationale: Supporting the family through grief is crucial.
A nurse is caring for several clients. The nurse should recognize that it is safe to administer tocolytic therapy to which of the following clients?
- A. A client who is experiencing fetal death at 32 weeks of gestation
- B. A client who is experiencing preterm labor at 26 weeks of gestation
- C. A client who is experiencing Braxton-Hicks contractions at 36 weeks of gestation
- D. A client who has a post-term pregnancy at 42 weeks of gestation
Correct Answer: B
Rationale: Tocolytic therapy is a medication given to delay preterm labor and prolong the pregnancy. It is safe and appropriate to administer tocolytic therapy to a client who is experiencing preterm labor at 26 weeks of gestation (option B) to help delay delivery and give time for other interventions to be initiated, such as administration of corticosteroids for fetal lung maturation and transfer to a facility with a NICU if necessary. The goal is to prevent premature birth and its associated complications.
The nurse is monitoring a client with severe preeclampsia. What assessment finding requires immediate intervention?
- A. Blood pressure of 150/90 mmHg.
- B. Urine output of 25 mL/hr.
- C. Headache relieved by acetaminophen.
- D. Deep tendon reflexes +2.
Correct Answer: B
Rationale: Oliguria (urine output <30 mL/hr) may indicate worsening renal function or severe complications in preeclampsia.
A postpartum client calls the pediatric clinic to report that her 4-day old female newborn has a spot of blood on her diaper. Which of the following statements made by the nurse is most appropriate?
- A. Your newborn may have a urinary infection, continue to breastfeed frequently
- B. Your newborn has jaundice so it may need phototherapy
- C. This is a normal finding due to withdrawal of maternal hormones
- D. Your baby has an immature immune system, continue to breastfeed frequently
Correct Answer: C
Rationale: Pseudomenstruation is a normal finding due to hormonal withdrawal.