Nokea
A nurse is providing teaching about terbutaline to a client who is experiencing preterm labor. Which of the following statement by client indicates an understanding of the teaching?
- A. "The medication could cause me to experience heart palpitation"
- B. "This medication could cause me to experience blurred vision"
- C. "This medication could cause me to experience ringing in my ears"
- D. "This medication could cause me to experience frequent "¦"
Correct Answer: A
Rationale: The correct answer is A. The statement "The medication could cause me to experience heart palpitations" indicates understanding because terbutaline, a beta-agonist used to stop preterm labor, can indeed cause heart palpitations as a common side effect due to its impact on the cardiovascular system. This shows the client has grasped a potential side effect of the medication.
The other choices are incorrect:
B: "This medication could cause me to experience blurred vision" - Blurred vision is not a common side effect of terbutaline.
C: "This medication could cause me to experience ringing in my ears" - Ringing in the ears is not a common side effect of terbutaline.
D: "This medication could cause me to experience frequent " - Incomplete statement, not indicating understanding of a specific side effect.
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Which teaching is most critical for a mother with gestational diabetes?
- A. Encourage a high-protein diet
- B. Teach the importance of blood glucose monitoring
- C. Advise on the importance of physical activity
- D. Monitor for preterm labor signs
Correct Answer: B
Rationale: The correct answer is B because monitoring blood glucose levels is crucial in managing gestational diabetes to prevent complications for both the mother and baby. By regularly monitoring blood glucose levels, the mother can adjust her diet and insulin intake accordingly to maintain optimal blood sugar levels. This helps in reducing the risk of adverse outcomes such as macrosomia and neonatal hypoglycemia.
Choice A is incorrect because while a balanced diet is important, focusing solely on high-protein intake may not address the specific needs of gestational diabetes management.
Choice C is also important for overall health, but blood glucose monitoring takes precedence in managing gestational diabetes.
Choice D is incorrect as monitoring for preterm labor signs is important in pregnancy but is not directly related to managing gestational diabetes.
A patient 11 weeks' gestation comes to the emergency room department with c/o dizziness, abdominal pain, and shoulder pain. Lab tests reveal a beta-hcg lower than expected level for gestational age
- A. Ultrasound confirms no intrauterine
- B. The nurse knows the most likely diagnostic is an ectopic pregnancy. What statement should the nurse use to explain to the patient?
- C. The baby is in the fallopian tube, the tube has ruptured and is causing bleeding
Correct Answer: B
Rationale: Step 1: Recognize Symptoms - Dizziness, abdominal pain, shoulder pain, low beta-hcg.
Step 2: Consider Ectopic Pregnancy - Symptoms align with ectopic pregnancy.
Step 3: Rule Out Miscarriage - Low beta-hcg indicates not viable intrauterine pregnancy (Choice A).
Step 4: Understand Ectopic Pregnancy - Explaining ectopic pregnancy (Choice C) and rupture to patient may cause distress.
Step 5: Communicate - Nurse should use simple, empathetic statement (Choice B) to explain the likely diagnosis.
Summary: Choice B is correct as it addresses the likely diagnosis without causing undue distress to the patient, unlike Choices A and C which may lead to confusion and anxiety.
A client in labor with ruptured membranes is diagnosed with chorioamnionitis. What is the priority nursing action?
- A. Administer prescribed antibiotics.
- B. Encourage the client to ambulate.
- C. Increase the oxytocin infusion rate.
- D. Perform a sterile vaginal examination.
Correct Answer: A
Rationale: The correct answer is A: Administer prescribed antibiotics. The priority nursing action in a client with chorioamnionitis is to administer antibiotics promptly to prevent infection spread to the fetus and mother. Antibiotics help treat the infection and reduce complications. Encouraging ambulation (B) may not be safe due to the risk of infection. Increasing oxytocin infusion rate (C) could worsen the infection. Performing a sterile vaginal examination (D) is contraindicated as it can introduce more bacteria. Administering antibiotics is the most urgent and effective intervention in this situation.
What is the most critical sign of fetal distress during labor?
- A. Accelerations in fetal heart rate
- B. Decreased variability in fetal heart rate
- C. Early decelerations in fetal heart rate
- D. Late decelerations in fetal heart rate
Correct Answer: D
Rationale: The correct answer is D: Late decelerations in fetal heart rate. Late decelerations indicate uteroplacental insufficiency, where the fetus is not receiving enough oxygen during contractions. This is critical as it can lead to fetal hypoxia and acidosis, posing a risk to the baby's well-being. Early decelerations (C) are generally benign and result from head compression during contractions. Accelerations (A) are a reassuring sign indicating fetal well-being. Decreased variability (B) can be concerning but is not as critical as late decelerations in indicating fetal distress.
A nurse is monitoring a client who has preeclampsia and is receiving magnesium sulfate by continuous IV infusion. Which of the following findings should the nurse reports to the provider?
- A. Blood pressure 148/94mm Hg
- B. Respiratory rate 14mm
- C. Urinary output 20 mL/hr
- D. 2+deep tendon reflexes
Correct Answer: A
Rationale: The correct answer is A: Blood pressure 148/94mm Hg. High blood pressure in a client with preeclampsia indicates worsening condition and potential for eclampsia. Magnesium sulfate is given to prevent seizures, so high blood pressure needs immediate provider attention.
Incorrect Choices:
B: Respiratory rate 14mm - This respiratory rate is within normal range.
C: Urinary output 20 mL/hr - Low urinary output should be monitored but is not the priority in this situation.
D: 2+deep tendon reflexes - Normal deep tendon reflexes are expected with magnesium sulfate therapy.