Nokea
The patient asks the nurse when her Nexplanon can be inserted. How does the nurse respond?
- A. after the delivery of your placenta
- B. only during your period
- C. while you are in labor
- D. during the delivery
Correct Answer: A
Rationale: The nurse would respond with option A, "after the delivery of your placenta." Nexplanon is a hormonal contraceptive implant that is typically inserted in the upper arm subdermally. It is recommended to wait until after the delivery of the placenta to reduce the risk of causing any harm to the fetus during pregnancy or labor. Inserting Nexplanon during labor or delivery is not recommended due to the potential risks involved.
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A pregnant client asks about the purpose of taking folic acid. What is the nurse's best response?
- A. It prevents gestational diabetes.
- B. It helps prevent neural tube defects.
- C. It supports fetal bone development.
- D. It reduces the risk of preterm labor.
Correct Answer: B
Rationale: Folic acid is essential for preventing neural tube defects like spina bifida during early fetal development.
A nurse is admitting a client who has a diagnosis of preterm labor. The nurse anticipates a prescription by the provider for which of the following medications? (Select all that apply.)
- A. Prostaglandin E2
- B. Indomethacin
- C. Magnesium sulfate
- D. Methylergonovine
Correct Answer: A
Rationale: A. Prostaglandin E2: Prostaglandin E2 is used to manage preterm labor by helping to ripen the cervix and promote contractions.
A nurse is caring for a client who is 4hr postpartum and is experiencing hypovolemic shock. Which of the following actions should the nurse take?
- A. Administer indomethacin
- B. Insert a second using a 22-gauge IV catheter.
- C. Insert an indwelling urinary catheter.
- D. Administer oxygen at 4L/min via nasal cannula.
Correct Answer: B
Rationale: The priority action for a client experiencing hypovolemic shock is to restore circulating volume. Inserting a second IV using a 22-gauge catheter would allow for rapid administration of IV fluids to help restore blood volume and improve circulation. This intervention is crucial in managing hypovolemic shock to prevent further complications and stabilize the client's condition. Administering indomethacin, inserting an indwelling urinary catheter, or administering oxygen, while potentially necessary in some cases, are not the immediate priority in managing hypovolemic shock.
The nurse discusses treatment for side effects of perimenopause. What education should be provided?
- A. Menopausal hormone therapy can decrease symptoms of menopause.
- B. Hot flashes are normal, and no one should need treatment for this symptom.
- C. Medications to decrease estrogen can help with insomnia.
- D. Depression is normal, so no treatment is needed.
Correct Answer: A
Rationale:
A nurse is assessing a newborn who is 48 hours old and has a maternal history of methadone use during pregnancy. Which of the following manifestations should the nurse identify as an indication of neonatal abstinence syndrome?
- A. Hyporeactivity
- B. Excessive high-pitched cry
- C. Acrocyanosis
- D. Respiratory rate of 50/min
Correct Answer: B
Rationale: Neonatal abstinence syndrome (NAS) occurs in newborns who were exposed to substances, such as methadone, while in the womb. Infants with NAS may exhibit excessive high-pitched crying as one of the manifestations. Other common symptoms of NAS include irritability, tremors, feeding difficulties, sweating, fever, vomiting, diarrhea, and poor weight gain. Therefore, in this case, the excessive high-pitched cry is a manifestation that the nurse should identify as an indication of neonatal abstinence syndrome.