Nokea
The client expresses concerns related to nausea in the first trimester of pregnancy. Which recommendation should the nurse make?
- A. Eat crackers while still in bed in the morning.
- B. Lie down and rest whenever nausea occurs.
- C. Eat more frequently throughout the day.
- D. Avoid food items containing ginger.
Correct Answer: A
Rationale: The nurse should instruct the client to eat dry crackers before rising from bed. This typically relieves some of the nausea. Lying down when the nausea occurs may increase heartburn and reflux, thereby increasing nausea. Eating frequently may increase heartburn and reflux, thereby increasing nausea. Food items with ginger may help to alleviate nausea and are recommended (rather than avoided), including ginger tea.
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The home care nurse is visiting the mother and her 6-day-old son. The nurse observes that the infant is sleeping in a crib on his back and has a blanket draped over his body. The mother had been sleeping in a nearby room. Which statements are appropriate for the nurse to make in response to this situation? Select all that apply.
- A. “I’m glad to see that you are sleeping while your baby sleeps.”
- B. “Having your baby sleep on his back reduces the risk of SIDS.”
- C. “It is best for you to sleep in the same room as your newborn.”
- D. “Position your baby on his tummy and side when he is awake.”
- E. “When using a blanket, always tuck its sides under the mattress.”
Correct Answer: A,B,D
Rationale: This is an appropriate statement. Sleeping while the infant sleeps will help the mother get the rest she needs. This is an appropriate statement. The American Academy of Pediatricians recommends the supine position for infant sleeping to decrease the risk of SIDS. The mother should be in close proximity and ready to respond when the infant wakes and/or cries, but she does not need to sleep in the same room as the infant. This is an appropriate statement. While awake the infant should be positioned prone and side-lying to help build neck muscles and decrease the chance of deformation plagiocephaly. Deformation plagiocephaly is a malformation of the skull caused by consistently lying on the back. A blanket, if used, should swaddle the infant rather than being draped over the infant. Swaddling helps prevent suffocation. Tucking the blanket sides under the mattress does not prevent suffocation.
The nurse assesses the client in her third trimester with suspected placenta previa. Which finding should the nurse associate with placenta previa?
- A. Cervix is 100% effaced
- B. Painless vaginal bleeding
- C. The fetal lie is transverse
- D. Absence of fetal movement
Correct Answer: B
Rationale: In placenta previa, the abnormal location of the placenta causes painless, bright red vaginal bleeding as the lower uterine segment stretches and thins. The nurse should not perform a vaginal examination to determine effacement on the client with suspected placenta previa. The lie of the fetus is not associated with placenta previa. An absence of fetal movement is always cause for concern but is not a primary symptom of placenta previa.
In the primigravid client, when is fetal movement typically felt for the first time?
- A. Between 10 and 14 weeks' gestation
- B. Between 16 and 20 weeks' gestation
- C. Between 22 and 26 weeks' gestation
- D. Between 28 and 32 weeks' gestation
Correct Answer: B
Rationale: Primigravid women typically feel fetal movement (quickening) between 16 and 20 weeks, later than multigravida women.
The experienced nurse is observing the new nurse determine the fetal position of the pregnant client using Leopold maneuver. The experienced nurse determines that the new nurse correctly identifies the first Leopold maneuver when placing the hands in which position illustrated first?
- A. Image A
- B. Image B
- C. Image C
- D. Image D
Correct Answer: B
Rationale: This illustration shows the first step of Leopold’s maneuver. The nurse palpates the fundus to determine which fetal body part (e.g., head or buttocks) occupies the uterine fundus. Image A shows the fourth Leopold maneuver. The nurse’s fingertips are used to determine the location of the cephalic prominence. Image C shows the third Leopold maneuver (“Pawlik maneuver”). During this maneuver the fetal part in the fundal region is compared with the part in the lower uterine segment. It is completed primarily to confirm that the fetus is in a cephalic (head) presentation. Image D shows the second Leopold maneuver. The second maneuver determines the location of the fetal back or spine.
The nurse advises a client with a history of miscarriage to monitor which symptom?
- A. Mild fatigue
- B. Vaginal spotting
- C. Increased appetite
- D. Normal fetal movement
Correct Answer: B
Rationale: Vaginal spotting may indicate a threatened miscarriage, requiring close monitoring and medical evaluation.