Nokea
A nurse is caring for several clients. The nurse should recognize that it is safe to administer tocolytic therapy to which of the following clients?
- A. A client who is experiencing fetal death at 32 weeks of gestation
- B. A client who is experiencing preterm labor at 26 weeks of gestation
- C. A client who is experiencing Braxton-Hicks contractions at 36 weeks of gestation
- D. A client who has a post-term pregnancy at 42 weeks of gestation
Correct Answer: B
Rationale: Tocolytic therapy is a medication given to delay preterm labor and prolong the pregnancy. It is safe and appropriate to administer tocolytic therapy to a client who is experiencing preterm labor at 26 weeks of gestation (option B) to help delay delivery and give time for other interventions to be initiated, such as administration of corticosteroids for fetal lung maturation and transfer to a facility with a NICU if necessary. The goal is to prevent premature birth and its associated complications.
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To prevent breast engorgement a new breastfeeding mother should be instructed to:
- A. Apply cold packs to the breast before feeding
- B. Breastfeed frequently and for adequate lengths of time to empty the breasts.
- C. Limit her intake of fluids for a few days
- D. Feed her infant no more than every 4 hours
Correct Answer: B
Rationale: Frequent breastfeeding helps prevent engorgement.
Before discharge, what health teaching should the nurse provide to a woman diagnosed with pelvic inflammatory disease (PID)?
- A. Endometriosis.
- B. Menopause.
- C. Ovarian hyperstimulation.
- D. Sexually transmitted infections.
Correct Answer: D
Rationale: PID is often caused by untreated STIs, so education about STIs is crucial.
Why is it important for nurses to approach the topic of sexual history with sensitivity and create a nonjudgmental and confidential environment?
- A. to increase patient satisfaction with the health-care provider
- B. to ensure that patients feel comfortable and supported during the assessment
- C. to promote healthy sexual behaviors among patients
- D. to comply with health-care regulations and standards
Correct Answer: B
Rationale:
A nurse is assessing a client who is at 27 weeks of gestation and has preeclampsia. Which of the following findings should the nurse report to the provider?
- A. Urine protein concentration 200 mg/ 24 hr.
- B. Creatinine 0.8 mg/ Dl
- C. Hemoglobin 14.8 g/ dL
- D. Platelet Count 60.000/ mm3
Correct Answer: D
Rationale: A platelet count of 60,000/mm3 is significantly low and can be indicative of thrombocytopenia, a potential complication of preeclampsia known as HELLP syndrome (Hemolysis, Elevated Liver enzymes, and Low Platelet count). Thrombocytopenia increases the risk of bleeding complications during pregnancy and delivery, requiring prompt evaluation and management by the healthcare provider. The nurse should report this finding immediately to prevent any adverse outcomes for the client and baby.
The nurse assigned to the care of newborn infants understands the importance of keeping these infants swaddled in a warm blanket to prevent heat loss. Why is this important in the care of the newborn?
- A. Chilling leads to increased heat production and greater oxygen needs.
- B. The newborn's metabolic rate is decreased.
- C. Evaporation will affect the newborn's ability to feed.
- D. The newborn will sleep more comfortably.
Correct Answer: A
Rationale: Preventing chilling reduces metabolic demands.