Nokea
The nurse advises the client to avoid which medication during pregnancy?
- A. Acetaminophen
- B. Aspirin
- C. Prenatal vitamins
- D. Iron supplements
Correct Answer: B
Rationale: Aspirin is generally avoided in pregnancy due to risks of bleeding and fetal complications, unlike acetaminophen, which is safer.
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The nurse advises the client to keep the newborn's crib free of which item?
- A. Soft toys and blankets
- B. Firm mattress
- C. Fitted sheet
- D. Crib bumpers
Correct Answer: A
Rationale: Soft toys and blankets in the crib increase the risk of suffocation and SIDS, and should be avoided.
The nurse’s assessment findings of the pregnant client include darkening of areola and nipple, presence of Goodell’s sign, leukorrhea, HR 124 bpm, dysuria, and heartburn. Of these findings, how many require further evaluation?
- A. 3
Correct Answer: 3
Rationale: There are three abnormal findings that require further evaluation. Leukorrhea needs to be distinguished from a vaginal infection, such as Candida albicans or a sexually transmitted infection. Heart rate can increase by 10 to 15 bpm during pregnancy, but an increase to 124 bpm is too high. Dysuria may be a sign of a UTI. Darkening of the areola and nipple, Goodell’s sign, and heartburn are normal findings during pregnancy and do not require further evaluation.
Which statement by the client indicates a need for further psychosocial support?
- A. I feel ready to bond with my baby.
- B. I am excited about becoming a mother.
- C. I feel worthless and overwhelmed daily.
- D. I have a great support system at home.
Correct Answer: C
Rationale: Feeling worthless and overwhelmed daily suggests potential depression, indicating a need for additional psychosocial support.
Which fetal heart rate must the nurse report immediately to the physician?
- A. 100 beats/minute
- B. 120 beats/minute
- C. 140 beats/minute
- D. 160 beats/minute
Correct Answer: A
Rationale: A fetal heart rate of 100 beats/minute is below the normal range (110-160 bpm) and may indicate fetal distress, requiring immediate reporting.
The client with mastitis asks the nurse if she should stop breastfeeding because she has developed a breast infection. Which response by the nurse is best?
- A. “Continuing to breastfeed will decrease the duration of your symptoms.”
- B. “Breastfeeding should only be continued if your symptoms decrease.”
- C. “Stop feeding for 24 hours until antibiotic therapy begins to take effect.”
- D. “It is best to stop breastfeeding because the infant may become infected.”
Correct Answer: A
Rationale: Continuing to breastfeed is recommended when the client has mastitis. If the breasts continue to be emptied by either breastfeeding or pumping, the duration of symptoms and the incidence of a breast abscess are decreased. Continuing to breastfeed will decrease the symptoms of mastitis; there is no need to wait for symptoms to decrease. Usually an oral penicillinase-resistant penicillin or cephalosporin that is safe for the infant while breastfeeding is given to treat mastitis. There is no need for the client to stop breastfeeding for 24 hours. The infant’s nose and throat are the most common sources of the organism that causes mastitis. Infants of women with mastitis generally remain well; thus, concern that the mother will infect the infant if she continues breastfeeding is unwarranted.