Nokea
During a prenatal visit, a gravid client is complaining of ptyalism. Which of the following nursing interventions is appropriate?
- A. Encourage the woman to brush her teeth carefully.
- B. Advise the woman to have her blood pressure checked regularly.
- C. Encourage the woman to wear supportive hosiery.
- D. Advise the woman to avoid eating rare meat.
Correct Answer: A
Rationale: Ptyalism (excessive salivation) can lead to oral hygiene issues, so encouraging careful tooth brushing is appropriate. Blood pressure checks, wearing supportive hosiery, and avoiding rare meat address other concerns but are unrelated to ptyalism.
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A patient with gestational hypertension is being monitored during labor. What is the most important factor to assess?
- A. Fetal heart rate
- B. Blood pressure
- C. Uterine contractions
- D. Fetal malpresentation
Correct Answer: B
Rationale: The correct answer is B: Blood pressure. In a patient with gestational hypertension, monitoring blood pressure is crucial to assess for worsening hypertension, which can lead to complications such as preeclampsia and eclampsia. Elevated blood pressure can affect both maternal and fetal well-being. Assessing fetal heart rate (A) is important but not the most critical factor in this scenario. Uterine contractions (C) are important but secondary to monitoring blood pressure. Fetal malpresentation (D) can impact delivery but is not the most vital factor to assess in a patient with gestational hypertension.
A father experiencing couvade syndrome is likely to exhibit which of the following symptoms/behaviors? Select all that apply.
- A. Heartburn.
- B. Promiscuity.
- C. Hypertension.
- D. Bloating.
Correct Answer: C
Rationale: Couvade syndrome involves sympathetic pregnancy symptoms in fathers, such as heartburn, bloating, and abdominal discomfort. Promiscuity is not typically associated with this condition.
A client makes the following statement after finding out that her pregnancy test is positive, 'This is not a good time. I am in college and the baby will be due during final exams!' Which of the following responses by the nurse would be most appropriate at this time?
- A. I’m absolutely positive that everything will turn out all right.
- B. I suggest that you e-mail your professors to set up an alternate plan.
- C. It sounds like you’re feeling a little overwhelmed right now.
- D. You and the baby’s father will find a way to get through the pregnancy.
Correct Answer: C
Rationale: Acknowledging the client's feelings of being overwhelmed is the most supportive response. Offering solutions or reassurance without first addressing the client's emotions may not be as effective.
A nurse is caring for a laboring person who is experiencing strong contractions. What is the most important intervention to support the laboring person during this time?
- A. provide comfort measures
- B. assist with breathing exercises
- C. provide reassurance and comfort
- D. administer antibiotics
Correct Answer: A
Rationale: The correct answer is A: provide comfort measures. Comfort measures such as massage, positioning, and relaxation techniques help the laboring person cope with the pain and intensity of contractions. By providing comfort, the nurse can help reduce stress and anxiety, promoting a more positive labor experience.
Choice B (assist with breathing exercises) can be helpful, but comfort measures are more essential for overall well-being during labor. Choice C (provide reassurance and comfort) is similar to the correct answer but lacks the specific action of providing comfort measures. Choice D (administer antibiotics) is irrelevant to the management of strong contractions and is not indicated unless there is a specific medical reason for antibiotics.
What are late FHR decelerations caused by?
- A. Altered cerebral blood flow
- B. Umbilical cord compression
- C. Uteroplacental insufficiency
- D. Meconium fluid
Correct Answer: C
Rationale: The correct answer is C: Uteroplacental insufficiency. Late FHR decelerations are caused by decreased blood flow and oxygen delivery to the fetus due to impaired uteroplacental circulation. This can result from conditions like placental abruption or placental insufficiency. Altered cerebral blood flow (A) is more related to early decelerations. Umbilical cord compression (B) typically causes variable decelerations. Meconium fluid (D) can lead to fetal distress but is not the primary cause of late decelerations.