Nokea
A pregnant woman is scheduled to undergo chorionic villus sampling (CVS) based on genetic family history. Which medication does the nurse anticipate will be administered?
- A. Magnesium sulfate
- B. Prostaglandin suppository
- C. RhoGAM if the patient is Rh-negative
- D. Betamethasone
Correct Answer: C
Rationale: The correct answer is C: RhoGAM if the patient is Rh-negative. During CVS, there is a risk of maternal-fetal blood mixing, especially if the patient is Rh-negative. RhoGAM is given to prevent sensitization to the Rh factor, which could lead to hemolytic disease in the newborn. Magnesium sulfate (A) is not indicated for CVS. Prostaglandin suppository (B) is used for cervical ripening or induction of labor, not for CVS. Betamethasone (D) is a corticosteroid given to pregnant women at risk of preterm delivery to promote fetal lung maturation, not indicated for CVS.
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Which advice to the patient is one of the most effective methods for preventing venous stasis?
- A. Sit with the legs crossed.
- B. Rest often with the feet elevated.
- C. Sleep with the foot of the bed elevated.
- D. Wear elastic stockings in the afternoon.
Correct Answer: B
Rationale: The correct answer is B: Rest often with the feet elevated. Elevating the feet helps to promote venous blood flow back to the heart, reducing the risk of venous stasis. When the legs are elevated, gravity assists in returning the blood to the heart. Sitting with the legs crossed (choice A) can actually impede blood flow. Sleeping with the foot of the bed elevated (choice C) may not be as effective as regularly elevating the feet throughout the day. Wearing elastic stockings in the afternoon (choice D) can provide some support but may not be as effective as elevating the feet.
The nurse is caring for a 45-year-old client who is scheduled to have a chorionic villus sampling. Which information is most important for the nurse to obtain from the client before the procedure?
- A. NPO status
- B. Blood type and Rh
- C. Weeks of gestation
- D. Maternal bleeding disorders
Correct Answer: D
Rationale: The correct answer is D: Maternal bleeding disorders. This information is crucial before a chorionic villus sampling to assess the risk of excessive bleeding during the procedure due to potential clotting issues. Maternal bleeding disorders can increase the risk of complications during the procedure.
A: NPO status is not as critical for this procedure as it does not typically require fasting.
B: Blood type and Rh are important for other purposes but not specifically needed before a chorionic villus sampling.
C: Weeks of gestation is important for determining the timing of the procedure but does not directly impact the safety or success of the procedure.
A school nurse is discussing the male reproductive system with the students in a high school health class. Which of the following information about the hormone testosterone should be included in the discussion?
- A. Testosterone is what makes boys more muscular than girls.'
- B. The level of testosterone in boys changes every month like female hormones do.'
- C. Testosterone is produced by the male prostate gland.'
- D. The production of testosterone usually stops by the time a man is fifty years old.'
Correct Answer: A
Rationale: Testosterone is responsible for the development of male secondary sexual characteristics, including increased muscle mass.
A nurse is providing home care to a home-bound patient treated with intravenous (IV) therapy and enteral nutrition. What is the home health nurse’s primary objective?
- A. Screening
- B. Education
- C. Dependence
- D. Counseling
Correct Answer: B
Rationale: Health promotion and education are traditionally the primary objectives of home care, yet at present most patients receive home care because they need nursing care. Screening is preventive care. The home health nurse focuses on patient and family independence. Counseling is through psychiatric care.
The nurse is caring for a pregnant client who was sent to the hospital for a biophysical profile. She is 37 weeks gestation with her second child, has gestational diabetes, and complains of decreased fetal movement for the last 24 hours. Which action should the nurse take first?
- A. Perform vital signs
- B. Call physician
- C. Perform glucose
- D. Place on fetal monitor
Correct Answer: D
Rationale: The correct answer is D: Place on fetal monitor. This action is crucial to assess the fetal well-being and monitor the baby's heart rate and movements. It helps in determining if the baby is in distress and requires immediate intervention. Performing vital signs (A) is important but not the priority in this situation. Calling the physician (B) can be done after the initial assessment on the fetal monitor. Performing glucose (C) is not the priority when the main concern is the well-being of the baby.