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The nurse is monitoring a client in active labor with ruptured membranes. What finding requires immediate action?
- A. Contractions every 3–5 minutes.
- B. Temperature of 100.4°F.
- C. Fetal heart rate of 100 beats/minute.
- D. Clear amniotic fluid.
Correct Answer: C
Rationale: The correct answer is C: Fetal heart rate of 100 beats/minute. A fetal heart rate of 100 beats/minute is bradycardia, indicating fetal distress and requiring immediate action to prevent adverse outcomes. Contractions every 3-5 minutes are normal in active labor. A temperature of 100.4°F indicates a low-grade fever but is not an immediate concern unless it continues to rise. Clear amniotic fluid is a normal finding after membrane rupture and does not require immediate action. Therefore, monitoring and addressing the fetal heart rate abnormalities are crucial in this situation.
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A client at 10 weeks' gestation reports frequent nausea. What dietary advice should the nurse provide?
- A. Consume small, frequent meals throughout the day.
- B. Avoid eating before going to bed.
- C. Drink large amounts of fluids with meals.
- D. Eat only three large meals daily.
Correct Answer: A
Rationale: The correct answer is A. Consuming small, frequent meals helps manage nausea by preventing an empty stomach, which can worsen symptoms. Eating smaller meals throughout the day can help stabilize blood sugar levels and provide a constant source of nutrients. This approach is recommended for managing nausea during early pregnancy.
Choice B is incorrect because avoiding eating before bed does not address the underlying issue of nausea during the day.
Choice C is incorrect because drinking large amounts of fluids with meals may worsen nausea by causing bloating and discomfort.
Choice D is incorrect because eating only three large meals daily can lead to periods of fasting in between meals, which may exacerbate nausea.
A young girl comes to the OB-GYN office to begin contraception. What is the most important information the nurse should find in the history before starting a contraceptive?
- A. Do your cramps prevent you from daily activities?
- B. When was your last menstrual period?
- C. How much water do you drink?
- D. How many pads do you soak per day during your cycle?
Correct Answer: A
Rationale: The correct answer is A: "Do your cramps prevent you from daily activities?" This question is crucial as it assesses the impact of menstrual cramps on the girl's quality of life, helping determine the suitability of different contraceptive options. Options B, C, and D are irrelevant to contraceptive choice and do not provide pertinent information regarding the girl's health or contraceptive needs.
The nurse is caring for a postpartum client with excessive bleeding. What is the priority nursing intervention?
- A. Administer IV fluids.
- B. Massage the uterine fundus.
- C. Notify the healthcare provider.
- D. Check the client's vital signs.
Correct Answer: B
Rationale: The correct answer is B: Massage the uterine fundus. This is the priority intervention because excessive bleeding postpartum may indicate uterine atony, which can lead to hemorrhage. Massaging the uterine fundus helps to stimulate uterine contractions and control bleeding. Administering IV fluids (A) can be important, but controlling bleeding takes precedence. Notifying the healthcare provider (C) can be done after implementing immediate interventions. Checking vital signs (D) is important, but addressing the underlying cause of bleeding is the priority.
A meconium stool can be differentiated from a transitional stool in the newborn because the meconium stool is
- A. Passed in first 12-24h of life
- B. Seen at 3 days
- C. Residue of a milk curd
- D. Lighter in color and looser in consistency
Correct Answer: A
Rationale: The correct answer is A because meconium stool is typically passed within the first 12-24 hours of life in newborns. Meconium is the earliest stool passed by a newborn and is composed of materials ingested while in the womb. Choices B, C, and D are incorrect because transitional stool is typically seen at 3 days, meconium is not a residue of milk curd, and meconium is darker in color and stickier in consistency compared to transitional stool.
Which of the following findings would indicate
- A. Reversal of a tubal ligation is easily done, with a an infant who may be considered preterm?
- B. Labia minora are larger than labia majora
- C. After this procedure, I must abstain from inter-
- D. Plantar creases cover two-thirds of foot
Correct Answer: D
Rationale: The correct answer is D because plantar creases covering two-thirds of the foot is a typical finding in Down syndrome. This is known as the Sandal gap sign, which is a characteristic feature of Down syndrome. The other choices are incorrect because: A is not related to any specific medical condition, B describes a normal anatomical variation, and C is incomplete and does not provide enough information to determine its relevance.