Nokea
A nurse is caring for a client who is 12 hr postpartum and has a third-degree perineal laceration. The client reports not having a bowel movement for 4 days. Which of the following medications should the nurse administer?
- A. Bisacodyl 10 mg rectal suppository
- B. Magnesium hydroxide 30 mL PO
- C. Famotidine 20 mg PO
- D. Loperamide 4 mg PO
Correct Answer: A
Rationale: A rectal suppository like bisacodyl is effective for relieving constipation and is safe for postpartum clients with perineal lacerations.
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A nurse is admitting a client to the labor and delivery unit when the client states, 'My water just broke.' Which of the following interventions is the nurse's priority?
- A. Perform Nitrazine testing.
- B. Assess the fluid.
- C. Check cervical dilation.
- D. Begin FHR monitoring.
Correct Answer: D
Rationale: The correct answer is D: Begin FHR monitoring. This is the priority because it assesses the well-being of the fetus immediately after the client's water breaks, ensuring timely detection of any fetal distress. Performing Nitrazine testing (A) or checking cervical dilation (C) can wait until after FHR monitoring. Assessing the fluid (B) may be important but not as urgent as monitoring the FHR.
Which of the following is a potential complication of maternal hyperemesis gravidarum?
- A. Preterm labor
- B. Fetal growth restriction
- C. Maternal dehydration
- D. All of the above
Correct Answer: D
Rationale: Hyperemesis gravidarum can lead to preterm labor, fetal growth restriction, and maternal dehydration.
Which of the following conditions should the nurse identify as being consistent with the adolescent's assessment findings? For each finding, click to specify if the assessment findings are consistent with trichomoniasis, gonorrhea, r candidiasis. Each finding may support more than one disease process.
- A. Abdominal assessment
- B. Vaginal discharge
- C. Heart rate
- D. Temperature
- E. Dyspareunia
- F. Condom usage
Correct Answer: A,B,D,E,F
Rationale: Abdominal assessment, vaginal discharge, temperature, dyspareunia, and condom usage are critical findings that may indicate infections, sexually transmitted diseases, or other health concerns requiring provider evaluation.
Which of the following is a potential complication of neonatal respiratory distress syndrome?
- A. Hypoglycemia
- B. Pneumonia
- C. Patent ductus arteriosus
- D. All of the above
Correct Answer: D
Rationale: The correct answer is D: All of the above. Neonatal respiratory distress syndrome can lead to complications such as hypoglycemia due to increased metabolic demands, pneumonia due to weakened immune system, and patent ductus arteriosus due to increased pulmonary blood flow. Hypoglycemia, pneumonia, and patent ductus arteriosus are all potential complications associated with neonatal respiratory distress syndrome. The other choices are incorrect as they do not encompass the range of potential complications associated with this condition.
A nurse is caring for a client immediately following the delivery of a stillborn fetus. Which of the following actions should the nurse take?
- A. Limit the amount of time the fetus is in the client’s room.
- B. Provide the client with photos of the fetus.
- C. Instruct the client that an autopsy should be performed within 24 hr.
- D. Inform the client that the law requires them to name the fetus.
Correct Answer: B
Rationale: The correct answer is B: Provide the client with photos of the fetus. This action allows the client to have tangible memories of their stillborn baby, aiding in the grieving process and facilitating closure. It is important for the client to have something to remember their child by, as it validates the existence of the baby and acknowledges the client's loss. It also promotes a sense of connection and remembrance. Providing photos can be a compassionate gesture that supports the client emotionally during this difficult time.
Choice A is incorrect because limiting the time the fetus is in the room may not consider the client's emotional needs. Choice C is incorrect as it may add unnecessary stress to the client. Choice D is incorrect as there is no legal requirement to name a stillborn fetus.