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The nurse is caring for a client in labor and is monitoring the fetal heart rate patterns. The nurse notes the presence of episodic accelerations on the electronic fetal monitor tracing. Which action is most appropriate?
- A. Notify the health care provider of the findings.
- B. Reposition the mother and check the monitor for changes in the fetal tracing.
- C. Take the mother's vital signs and tell the mother that bed rest is required to conserve oxygen.
- D. Document the findings and tell the mother that the pattern on the monitor indicates fetal well-being.
Correct Answer: D
Rationale: The correct answer is D: Document the findings and tell the mother that the pattern on the monitor indicates fetal well-being. This is the most appropriate action because episodic accelerations in fetal heart rate patterns are a reassuring sign of fetal well-being. By documenting the findings and informing the mother of this, the nurse can provide reassurance and promote a positive birthing experience.
Choice A is incorrect because notifying the health care provider is not necessary for this normal finding. Choice B is incorrect because repositioning the mother and checking the monitor for changes is not needed when episodic accelerations are present. Choice C is incorrect because taking the mother's vital signs and prescribing bed rest is unnecessary and not indicated based on the fetal heart rate pattern.
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Why would FAM not be appropriate for the nurse to recommend to a perimenopausal person?
- A. At that age, people do not have intercourse on a regular basis.
- B. They are married and do not need contraception.
- C. They have irregular menstrual periods.
- D. Pregnancy is not a concern when a person is perimenopausal.
Correct Answer: C
Rationale: The correct answer is C because perimenopausal individuals often have irregular menstrual periods, making FAM less reliable for tracking ovulation. Irregular periods can make it challenging to accurately predict fertile days. Choice A is incorrect because FAM is not solely for contraception but also for fertility awareness. Choice B is incorrect as FAM can still be used for tracking fertility even if contraception is not needed. Choice D is incorrect because while pregnancy risk decreases during perimenopause, it is not zero, and FAM can still be helpful for those who wish to avoid pregnancy.
A nurse is teaching about clomiphene citrate to a client who is experiencing infertility. Which of the following adverse effect should the nurse include?
- A. Tinnitus
- B. Urinary Frequency
- C. Breast Tenderness
- D. Chills
Correct Answer: C
Rationale: The correct answer is C: Breast Tenderness. Clomiphene citrate is a medication commonly used to induce ovulation in women experiencing infertility. Breast tenderness is a common adverse effect due to the hormonal changes caused by the medication. Tinnitus (A), urinary frequency (B), and chills (D) are not typically associated with clomiphene citrate use. Tinnitus is more commonly associated with ototoxic medications, urinary frequency may be seen with diuretics, and chills are usually a symptom of infections or fevers.
A nurse is reinforcing teaching about reducing perineal infection with a client following a vaginal delivery. Which of the following should the nurse include in the teaching? (Select all that apply.)
- A. Blot the perineal area dry after cleansing.
- B. Clean the perineal area from front to back.
- C. Perform hand hygiene before and after voiding.
- D. Wash the perineal area using a squeeze bottle of warm water after each voiding.
Correct Answer: A
Rationale: Correct Answer: A - Blot the perineal area dry after cleansing.
Rationale: Blotting the perineal area dry after cleansing helps prevent moisture accumulation, reducing the risk of perineal infection. Moisture can create a favorable environment for bacterial growth and infection. This practice also helps maintain skin integrity and promotes healing post-vaginal delivery.
Summary of other choices:
B: Cleaning the perineal area from front to back is important to prevent introducing fecal bacteria to the urinary tract but is not directly related to reducing perineal infection.
C: Performing hand hygiene before and after voiding is crucial for infection prevention but does not directly address reducing perineal infection.
D: Washing the perineal area using a squeeze bottle of warm water after each voiding can be beneficial for cleanliness but does not specifically address reducing perineal infection like blotting dry after cleansing does.
Placental circulation is dependent on maternal circu- tions for preventing sudden infant death syndrome? lation. In which maternal circumstances is placental Select all that apply. circulation impeded? Select all that apply.
- A. Position newborns in the prone position to
- B. Hypotension
- C. Pre-eclampsia
- D. Avoid soft bedding or pillows in the newborn's
Correct Answer: B
Rationale: The correct answer is B: Hypotension. Hypotension in the mother can result in decreased blood flow to the placenta, affecting placental circulation and oxygen delivery to the fetus, increasing the risk of sudden infant death syndrome.
A: Positioning newborns in the prone position does not directly impede placental circulation.
C: Pre-eclampsia can affect placental circulation due to high blood pressure, but it is not the only maternal condition that can impede placental circulation.
D: Avoiding soft bedding or pillows in the newborn's crib is related to safe sleep practices but does not directly impede placental circulation.
The nurse assures the breastfeeding mother that she will know that her infant is getting an adequate supply of breast milk if the infant gains weight and:
- A. Rarely sucks on a pacifier.
- B. Ha several hard stools daily
- C. Voids 6 or more times a day
- D. Awakens to feed every 4 hours
Correct Answer: C
Rationale: The correct answer is C: Voids 6 or more times a day. Adequate breast milk intake is indicated by frequent urination (6 or more times/day) in infants. This shows the infant is hydrated and receiving enough milk. The other choices are incorrect because A) pacifier use doesn't indicate milk supply, B) hard stools can be a sign of dehydration or other issues, and D) feeding every 4 hours is a general guideline but not a definitive indicator of milk supply.