Nokea
A woman had a miscarriage at 12 weeks' gestation and had D&C,
- A. While you are assessing her response to loss, she tells you she had
- B. Based on your assessment what nursing intervention would you use first?
- C. You ask her what items she bought for the baby
Correct Answer: B
Rationale: The correct answer is B because the priority in nursing care after a miscarriage and D&C is to assess the woman's physical and emotional well-being. By using the nursing intervention of assessment first, the nurse can determine any immediate needs for pain management, emotional support, or further medical intervention. This helps in providing individualized care and addressing any potential complications promptly.
Choice A is incorrect because assessing her response to loss comes after ensuring her immediate physical and emotional needs are met. Choice C is incorrect as it focuses on material items rather than the woman's well-being. Choice D is incomplete and does not provide a viable option for nursing intervention.
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The nurse provides education regarding male sterilization. What important information is provided?
- A. “Many people have vasectomies reversed.â€
- B. “You will need to return to the office to check for sperm in your ejaculate.â€
- C. “You will be sterile after 3 months.â€
- D. “Vasectomy consent forms must have both partners’ consent.â€
Correct Answer: B
Rationale: The correct answer is B: "You will need to return to the office to check for sperm in your ejaculate." This information is crucial as it ensures the success of the sterilization procedure. By checking for sperm in the ejaculate, the effectiveness of the vasectomy can be confirmed. This step is important to ensure that the individual is indeed sterile and can rely on the procedure for contraception.
Choice A is incorrect because vasectomy reversal is not always successful and should not be assumed. Choice C is incorrect as sterility is not immediate and may take several months after the procedure. Choice D is incorrect as consent forms for vasectomy typically require only the individual undergoing the procedure to give consent.
In summary, choice B is correct because it emphasizes the need for follow-up to confirm sterility, while the other choices provide incorrect or irrelevant information regarding male sterilization.
A client at 37 weeks' gestation reports severe itching without a rash. What condition should the nurse suspect?
- A. Preeclampsia.
- B. Cholestasis of pregnancy.
- C. Gestational diabetes.
- D. Fungal infection.
Correct Answer: B
Rationale: The correct answer is B: Cholestasis of pregnancy. Severe itching without a rash in a pregnant client at 37 weeks' gestation is concerning for cholestasis of pregnancy, a condition characterized by impaired bile flow. This can lead to elevated bile acids, causing itching. Preeclampsia (choice A) presents with hypertension and proteinuria. Gestational diabetes (choice C) manifests with high blood sugar levels. Fungal infection (choice D) typically presents with visible skin changes like a rash, which is absent in this case. In summary, cholestasis of pregnancy is the most likely explanation for severe itching in this scenario.
A charge nurse is teaching a group of staff nurses about fetal monitoring during labor. Which of the following findings should the charge nurse instruct the staff members to report to the provider?
- A. Contraction durations of 95 to 100 seconds
- B. Contraction frequency of 2 to 3 min apart
- C. Absent early deceleration of fetal heart rate
- D. Fetal heart rate is 140/min
Correct Answer: A
Rationale: The correct answer is A: Contraction durations of 95 to 100 seconds. Prolonged contractions can indicate uterine hyperstimulation, leading to decreased fetal oxygenation. Staff should report this to the provider for further evaluation and management.
Explanation:
1. Contraction durations of 95 to 100 seconds are prolonged and may indicate uterine hyperstimulation, potentially compromising fetal oxygenation.
2. Reporting this finding to the provider allows for timely intervention to prevent fetal distress.
3. Choices B, C, and D do not directly indicate a concern for fetal well-being during labor and would not require immediate reporting to the provider.
The nurse is performing a nonstress test. What result indicates a reactive test?
- A. No fetal movements noted.
- B. Two accelerations in 20 minutes.
- C. Baseline fetal heart rate of 170 beats/minute.
- D. Variable decelerations.
Correct Answer: B
Rationale: The correct answer is B because two accelerations in 20 minutes are indicative of a reactive nonstress test. This pattern suggests that the fetal heart rate is reacting appropriately to fetal movement, indicating good oxygenation and neurologic integrity. Choice A is incorrect as fetal movements are essential for the test. Choice C is incorrect as a baseline heart rate of 170 bpm is considered high. Choice D is incorrect as variable decelerations are concerning for fetal distress.
What is the best position for a laboring mother with a suspected occiput posterior position?
- A. Encourage side-lying position
- B. Place the mother in lithotomy position
- C. Encourage ambulation to facilitate descent
- D. Use a peanut ball to widen the pelvis
Correct Answer: D
Rationale: The correct answer is D. Using a peanut ball widens the pelvis, which can help rotate the baby into an optimal position for birth. This position can aid in reducing the likelihood of prolonged labor and the need for interventions. Encouraging side-lying position (A) may not provide the necessary pelvic widening. Placing the mother in lithotomy position (B) can impede the baby's descent. Encouraging ambulation (C) may not specifically address the occiput posterior position and may not provide enough pelvic opening.