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The nurse is monitoring a client during the second stage of labor. What finding indicates that birth is imminent?
- A. Client reports the urge to push.
- B. Contractions are irregular.
- C. Fetal heart rate is 140 beats/minute.
- D. Cervix is dilated to 8 cm.
Correct Answer: A
Rationale: The urge to push is a sign that the baby is descending, indicating that delivery is near.
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The nurse is monitoring a pregnant client with gestational hypertension. What is the primary complication to prevent?
- A. Preterm labor.
- B. Placenta previa.
- C. Eclampsia.
- D. Abruptio placentae.
Correct Answer: C
Rationale: Gestational hypertension can progress to eclampsia, characterized by seizures, and requires close monitoring.
A patient is taking oral contraceptives and asks whether they will still be effective if she has diarrhea. What should the nurse respond?
- A. Oral contraceptives will still work if taken with food.
- B. Oral contraceptives may be less effective during diarrhea due to absorption issues.
- C. Oral contraceptives need to be stopped for 7 days when experiencing diarrhea.
- D. Oral contraceptives will be more effective during diarrhea due to faster metabolism.
Correct Answer: B
Rationale: Diarrhea can reduce the absorption of oral contraceptives, potentially making them less effective. Choice A is incorrect because food does not always affect oral contraceptive absorption. Choice C is incorrect because there is no need to stop the contraceptives, but additional methods may be recommended during diarrhea. Choice D is incorrect because diarrhea does not increase the effectiveness of oral contraceptives.
A client in the first trimester reports nausea. What dietary recommendation should the nurse make?
- A. Eat dry crackers before getting out of bed.
- B. Avoid eating throughout the day.
- C. Increase intake of spicy foods.
- D. Consume large, infrequent meals.
Correct Answer: A
Rationale: Dry crackers before rising can help manage nausea by stabilizing blood sugar and reducing gastric discomfort.
A patient is about to undergo an amniocentesis. tion on her postpartum clients. Which client has a Which procedures should the nurse perform? Select high risk for postpartum hemorrhage? Select all all that apply.
- A. Have the patient give verbal consent for the
- B. Client who delivered vaginally at 40 weeks procedure.
- C. Client who delivered by cesarean delivery because
- D. Assess for bleeding disorders.
Correct Answer: A
Rationale: Having the patient give verbal consent for the procedure is a standard practice and an important step to ensure that the patient understands the risks and benefits of the amniocentesis.
A 28-year-old patient has decided to use the patch contraception. The nurse is educating her on the best site to use. Where is the best place to put the patch? Select one that does not that apply.
- A. Buttocks
- B. Leg
- C. Breast
- D. Arm
Correct Answer: C
Rationale: The best sites for applying the contraceptive patch are the buttocks, arm, and leg. These areas have sufficient fat and are away from areas that might rub off the patch. Choice B (Neck) is incorrect as the neck is not recommended for patch application due to the potential for irritation and the high blood flow area. Choice C (Breast) is not recommended because the breast tissue may affect the adhesion of the patch.