Nokea
A woman is 16 weeks pregnant and she had cramping backache and mild bleeding for the past 3 days. The HCP determines she is dilated 2cm, 10% effaced, membranes intact. She's crying and saying to the nurse is my baby going to be okay? In addition to acknowledging the patient's fear the nurse should also say:
- A. Your cervix has begun to dilate, this is a serious sign, we will continue to monitor you and the baby for now
- B. I really can't say but when your physicians arrive, I'll ask her talk to you about it
- C. You baby will be fine, we will start an IV and get this stopped in no time at all
- D. You are going to miscarry, but you should be relieved because most miscarriages are the result of abnormalities in the fetus
Correct Answer: A
Rationale: Step 1: Acknowledge the patient's fear and anxiety.
Step 2: Provide a clear and honest response regarding the situation.
Step 3: Explain the significance of cervical dilation at 16 weeks.
Step 4: Assure the patient that they will be closely monitored.
Step 5: Offer support and comfort to the patient.
Summary:
Choice A is correct because it addresses the patient's concerns, acknowledges the seriousness of the situation, provides information about cervical dilation, and reassures the patient about monitoring. Choices B, C, and D are incorrect because they do not provide accurate information or address the situation appropriately, which could further distress the patient.
You may also like to solve these questions
A nurse is providing nutritional guidance to a client who is pregnant and follows a vegan diet. The client asks the nurse which foods she should eat to ensure adequate calcium intake. The nurse should instruct the client that which of the following foods has the highest amount of calcium?
- A. ½ cup cubed avocado
- B. 1 large banana
- C. 1 medium potato
- D. 1 cup cooked broccoli
Correct Answer: D
Rationale: The correct answer is D: 1 cup cooked broccoli. Broccoli is a good source of calcium, with approximately 70 mg per cup. This is higher than the other options provided. Avocado, banana, and potato are not significant sources of calcium compared to broccoli. Broccoli is a suitable choice for a pregnant vegan to ensure adequate calcium intake. It is important for the client to consume a variety of plant-based calcium-rich foods to meet their nutritional needs during pregnancy.
A nurse is receiving laboratory results for a term newborn who is 24 hr. old. Which of the following results require intervention by the nurse?
- A. WBC count 10,000/mm3
- B. Platelets 180,000/mm3
- C. Hemoglobin 20g/dL
- D. Glucose 20 mg/dL
Correct Answer: D
Rationale: The correct answer is D because a glucose level of 20 mg/dL in a term newborn is significantly low and requires immediate intervention by the nurse. Low glucose levels can lead to hypoglycemia, which can be harmful to the newborn's brain development and overall health. A WBC count of 10,000/mm3 is within normal range for a newborn. Platelets of 180,000/mm3 and hemoglobin of 20g/dL are also within normal limits for a term newborn and do not require intervention.
Which finding in a laboring mother requires immediate intervention?
- A. Contractions occurring every 5 minutes
- B. Late decelerations on fetal heart monitor
- C. Early decelerations on fetal heart monitor
- D. Elevated maternal temperature during labor
Correct Answer: D
Rationale: The correct answer is D: Elevated maternal temperature during labor. This finding indicates a potential infection, such as chorioamnionitis, which can be harmful to both the mother and the baby if not promptly treated. Immediate intervention is necessary to prevent complications like sepsis.
Contractions every 5 minutes (A) are within the normal range for active labor. Late decelerations (B) can indicate uteroplacental insufficiency and require monitoring but not immediate intervention unless persistent. Early decelerations (C) are usually benign and do not typically require immediate action.
A nurse is giving post-op teaching to a person after a surgical abortion. What education should be provided?
- A. Report bleeding that is heavy, soaks more than two pads per hour for 2 hours.
- B. You can resume vaginal coitus the next day.
- C. You do not need to return to the clinic for follow-up.
- D. You should use tampons if your bleeding is heavy.
Correct Answer: A
Rationale: The correct answer is A because heavy bleeding post-surgical abortion can indicate a complication like hemorrhage, so prompt reporting is crucial. Choice B is incorrect as resuming vaginal intercourse too soon can increase the risk of infection. Choice C is incorrect because follow-up care is essential to monitor for complications. Choice D is incorrect as tampons should be avoided to reduce the risk of infection. In summary, choice A is correct as it prioritizes patient safety and early detection of complications.
A patient has had four vaginal deliveries. What barrier contraceptive method’s efficacy is affected by this history?
- A. internal condom
- B. external condom
- C. cervical cap
- D. contraceptive gel
Correct Answer: C
Rationale: The correct answer is C: cervical cap. This barrier contraceptive method's efficacy is affected by the patient's history of four vaginal deliveries due to changes in the cervix and vaginal canal post-deliveries. The cervical cap relies on proper placement over the cervix to prevent sperm from entering the uterus. However, after multiple vaginal deliveries, the cervix may become less firm and may have altered shape or size, leading to reduced effectiveness of the cervical cap.
A: Internal condom and B: external condom are not affected by the history of vaginal deliveries as they do not rely on cervical fit for efficacy.
D: Contraceptive gel is not directly affected by the number of vaginal deliveries as it is applied externally and does not rely on cervical anatomy for effectiveness.