Nokea
The nurse receives a phone call from a pregnant patient who states she has not felt the baby move. Identify the first question for the nurse to ask the patient.
- A. Have you experienced any recent vaginal bleeding?
- B. Have you experienced any recent vaginal discharge?
- C. How many weeks pregnant are you?
- D. When was the last time you felt the baby move?
Correct Answer: D
Rationale: The correct first question for the nurse to ask the patient is D: When was the last time you felt the baby move? This question is crucial because it helps assess the fetal well-being and can indicate any potential issues with the baby's health or development. It allows the nurse to determine if there has been a recent decrease in fetal movements, which could be a sign of distress. Asking about vaginal bleeding or discharge (choices A and B) may not provide immediate insight into the baby's well-being. Question C is relevant but not as urgent as knowing when the baby was last felt moving.
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A client has just received synthetic prostaglandins for the induction of labor. The nurse plans to monitor the client for which of the following side effects?
- A. Nausea and uterine tetany.
- B. Hypertension and vaginal bleeding.
- C. Urinary retention and severe headache.
- D. Bradycardia and hypothermia.
Correct Answer: A
Rationale: Synthetic prostaglandins can cause nausea and uterine tetany, which are common side effects. The nurse should monitor for these and other potential complications.
A 6-month-old child has been diagnosed with a significant hearing loss. Which of the following complications that occurred immediately after delivery could have resulted in this condition?
- A. Necrotizing enterocolitis.
- B. Hypoglycemia.
- C. Bronchopulmonary dysplasia.
- D. Kernicterus.
Correct Answer: D
Rationale: Kernicterus, caused by severe jaundice, can lead to hearing loss due to bilirubin toxicity in the brain.
In a prenatal education class, the nurse is reviewing the importance of using relaxation techniques during labor. Which patient statement will the nurse need to correct?
- A. We will practice relaxation techniques only in a quiet setting so I can focus.'
- B. Relaxation is important during labor because it will help me conserve my energy.'
- C. If I relax in between contractions, my baby will get more oxygen during labor.'
- D. My partner and I will practice relaxation throughout the remainder of my pregnancy.'
Correct Answer: A
Rationale: The correct answer is A because relaxation techniques should be practiced not just in quiet settings but also during labor, regardless of the environment. This is important to help manage pain and promote a smoother labor process. Choice B is correct as relaxation can indeed help conserve energy. Choice C is incorrect as oxygenation to the baby is not directly related to the mother's relaxation between contractions. Choice D is also incorrect as relaxation techniques should be practiced specifically during labor as well, not just throughout the pregnancy.
A nurse provides immunization to children and adults through the public health department. Which type of health care is the nurse providing?
- A. Primary care
- B. Preventive care
- C. Restorative care
- D. Continuing care
Correct Answer: B
Rationale: Preventive care includes immunizations, screenings, counseling, crisis prevention, and community safety legislation.
Which analysis of maternal serum is the best predictor of chromosomal abnormalities in the fetus?
- A. Biophysical profile
- B. Multiple-marker screening
- C. Lecithin-to-sphingomyelin ratio
- D. Blood type and crossmatch of maternal and fetal serum
Correct Answer: B
Rationale: The correct answer is B: Multiple-marker screening. This analysis measures levels of certain proteins and hormones in maternal serum to assess the risk of chromosomal abnormalities in the fetus. It is considered the best predictor because abnormal levels of these markers can indicate conditions like Down syndrome. Biophysical profile (A) assesses fetal well-being but does not directly predict chromosomal abnormalities. Lecithin-to-sphingomyelin ratio (C) is used to assess fetal lung maturity, not chromosomal abnormalities. Blood type and crossmatch (D) are important for identifying Rh incompatibility but do not predict chromosomal abnormalities.