Nokea
A client at 34 weeks' gestation reports regular uterine contractions. What is the nurse's priority action?
- A. Encourage ambulation to relieve discomfort.
- B. Perform a sterile vaginal examination.
- C. Assess fetal heart rate and contraction pattern.
- D. Administer an analgesic as prescribed.
Correct Answer: C
Rationale: Assessing fetal heart rate and contraction pattern is crucial to evaluate for preterm labor.
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A pregnant client reports frequent urination and lower abdominal pressure at 36 weeks. What should the nurse explain?
- A. This is a sign of preterm labor.
- B. This indicates urinary tract infection.
- C. This is common due to fetal descent.
- D. This is caused by Braxton Hicks contractions.
Correct Answer: C
Rationale: As the fetus descends into the pelvis (lightening), increased pressure on the bladder causes frequent urination.
The nurse is monitoring a pregnant client with suspected gestational hypertension. What finding confirms the diagnosis?
- A. Proteinuria.
- B. Blood pressure of 140/90 mmHg on two occasions.
- C. Edema of the hands and feet.
- D. Elevated blood glucose levels.
Correct Answer: B
Rationale: Gestational hypertension is diagnosed by consistent readings of 140/90 mmHg or higher without proteinuria.
What two steps of the CJMM are included in the assessment step of the nursing process?
- A. noticing cues and evaluating outcomes
- B. analyzing cues and generating solutions
- C. noticing and analyzing cues
- D. analyzing cues and taking action
Correct Answer: A
Rationale: In the assessment step of the nursing process, two steps of the CJMM (Clinical Judgment Model) that are included are noticing cues and evaluating outcomes. Noticing cues involves observing and recognizing relevant information or data related to the patient's health status, while evaluating outcomes involves assessing the effectiveness of the nursing interventions and patient responses to the care provided. By noticing cues, nurses gather information that guides their decision-making process, and by evaluating outcomes, they determine the impact of their actions on the patient's health and adjust the plan of care as needed. These two steps are essential in the assessment phase as they contribute to developing a comprehensive understanding of the patient's needs and progress towards achieving desired health outcomes.
The nurse is educating a male patient on how a vasectomy works. What is the best explanation for this procedure?
- A. The procedure blocks the sperm from entering into the semen and being ejaculated.
- B. The procedure removes the testicle so that sperm are not made.
- C. The tube that carries seminal fluid is blocked, causing no semen to be ejaculated.
- D. The procedure kills all sperm so they are unable to make it to the ovulated egg.
Correct Answer: A
Rationale: A vasectomy involves blocking or cutting the vas deferens to prevent sperm from being ejaculated with semen, making it an effective method of contraception. Choice B is incorrect because the testicles are not removed during a vasectomy, only the vas deferens is altered. Choice C is incorrect because seminal fluid is still produced, but sperm are prevented from entering it. Choice D is incorrect because sperm are not killed, but rather prevented from mixing with semen.
A couple who has stated that they are LGBTQIA+ during prior visits arrives at the clinic for prenatal care. What can the nurse say in the waiting area to help them feel welcome and safe?
- A. You can take this tablet to an area in the waiting room and check in. Then bring the tablet back to me when you are done.
- B. Are you pregnant? Your paperwork says your name is Tom.
- C. You can have a seat, and a person from the LGBTQIA+ office will come to assist you.
- D. Here is our paperwork. It doesn't have a box for your sex, but you can write it next to the gender box.
Correct Answer: A
Rationale: Providing a neutral and respectful approach helps create a welcoming environment for LGBTQIA+ patients.