Nokea
A 28-year-old primigravida admitted to antepartum unit with a diagnosis of hyperemesis gravidarum. Nursing care is based on which of the following?
- A. Assess for dehydration and starvation
- B. Isolated from family
- C. This condition is caused by psychogenic factor
- D. Similar to morning sickness
Correct Answer: A
Rationale: Rationale for Correct Answer (A): Assessing for dehydration and starvation is crucial in managing hyperemesis gravidarum, as it can lead to serious complications for both the mother and the fetus. Dehydration can result from persistent vomiting and may require intravenous fluids. Starvation can occur due to poor nutrient intake. Monitoring these factors helps in providing appropriate treatment and preventing further health issues.
Summary of Incorrect Choices:
B: Isolating the patient from family is not necessary and can have negative psychological impacts. Support from family is crucial in managing hyperemesis gravidarum.
C: Hyperemesis gravidarum is a physical condition related to pregnancy, not a psychogenic factor.
D: Hyperemesis gravidarum is more severe and persistent than morning sickness, requiring different management strategies.
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The nurse is assessing a client in the second stage of labor. What is the nurse's priority assessment?
- A. Frequency of contractions.
- B. Cervical dilation.
- C. Fetal descent and position.
- D. Intensity of contractions.
Correct Answer: C
Rationale: The correct answer is C: Fetal descent and position. In the second stage of labor, the priority assessment is to monitor fetal descent and position to ensure the baby is progressing through the birth canal correctly. This assessment helps determine if interventions are needed to prevent complications such as fetal distress or prolonged labor. Assessing the frequency of contractions (A) and cervical dilation (B) are important but not the priority in the second stage. Intensity of contractions (D) is also important but not as crucial as monitoring fetal descent and position.
What is the best nursing action for a newborn experiencing hypothermia?
- A. Place the newborn in skin-to-skin contact with the mother
- B. Provide a warm blanket and monitor temperature
- C. Administer IV fluids to stabilize temperature
- D. Monitor glucose levels for hypoglycemia
Correct Answer: A
Rationale: The correct answer is A: Place the newborn in skin-to-skin contact with the mother. This is the best nursing action for a newborn experiencing hypothermia because it provides immediate and effective warmth transfer from the mother to the baby. Skin-to-skin contact helps regulate the newborn's body temperature, promotes bonding, and enhances breastfeeding initiation.
Choice B is incorrect because while providing a warm blanket is important, skin-to-skin contact with the mother is more effective in quickly raising the newborn's temperature. Choice C is incorrect because administering IV fluids is not the first-line treatment for hypothermia in newborns. Choice D is incorrect because monitoring glucose levels for hypoglycemia is important but addressing the hypothermia should take precedence.
A nurse is caring for a client who is in the transition phase of labor. Which of the following...
- A. Assist the client to void every 3 hr.
- B. Monitor contractions every 30 min.
- C. Place the client into a lithotomy position.
- D. Encourage the client to use a pant-blow breathing pattern.
Correct Answer: B
Rationale: The correct answer is B: Monitor contractions every 30 min. During the transition phase of labor, contractions are typically intense and frequent. Monitoring contractions every 30 minutes allows the nurse to assess the progress of labor and ensure the safety of both the mother and the baby. This helps in identifying any abnormalities or complications that may arise during this critical stage.
A: Assisting the client to void every 3 hr is important, but it is not specific to the transition phase of labor.
C: Placing the client into a lithotomy position is not recommended during the transition phase as it can restrict blood flow and increase the risk of complications.
D: Encouraging the client to use a pant-blow breathing pattern is a relaxation technique more suited for the earlier stages of labor, not the transition phase.
The nurse is caring for a client in labor with a history of cesarean delivery. What is a priority assessment?
- A. Assess for signs of uterine rupture.
- B. Monitor maternal temperature hourly.
- C. Check for signs of preeclampsia.
- D. Assess for excessive fetal movement.
Correct Answer: A
Rationale: The correct answer is A: Assess for signs of uterine rupture. This is the priority assessment because a history of cesarean delivery puts the client at higher risk for uterine rupture during labor. Signs of uterine rupture include severe abdominal pain, abnormal fetal heart rate patterns, and vaginal bleeding. Early detection and intervention are crucial for the safety of both the mother and the baby. Monitoring maternal temperature (B) is important but not as critical as assessing for uterine rupture. Checking for signs of preeclampsia (C) is also important but not a priority in this specific scenario. Assessing for excessive fetal movement (D) is not a priority assessment in this case.
A nurse is educating a prenatal client on pregnancy 140 to 90 bpm that begins with the contraction changes and her gastrointestinal system. Which and gradually returns to the normal baseline statement is correct?
- A. Because of increased saliva production during related to? pregnancy, the client should use a medium to hard
- B. Uteroplacental insufficiency toothbrush to prevent plaque.
- C. Umbilical cord compression
- D. Heartburn may be relieved by sitting up after
Correct Answer: D
Rationale: The correct answer is D: Heartburn may be relieved by sitting up after. This is because during pregnancy, the growing uterus can push stomach acids upward, causing heartburn. Sitting up after eating can help prevent acid reflux by allowing gravity to keep stomach contents down.
Choice A is incorrect as increased saliva production during pregnancy is not related to toothbrush hardness. Choice B is incorrect because uteroplacental insufficiency is not related to the client's gastrointestinal system. Choice C is incorrect as umbilical cord compression is a separate issue and not related to heartburn relief.