Nokea
The nurse in a clinic is teaching a client of childbearing age about recommended folic acid supplements. Which of the following defects can occur in the fetus or neonate as a result folic acid deficiency?
- A. iron deficiency anemia
- B. Poor bone formation
- C. Macrosomia fetus
- D. Neural tube defect
Correct Answer: D
Rationale: Folic acid is essential for the development of the neural tube in the fetus. When a pregnant woman has a deficiency in folic acid, it can lead to neural tube defects in the fetus. Neural tube defects are serious birth defects that affect the brain, spine, or spinal cord of the baby. The most common types of neural tube defects include spina bifida and anencephaly. Therefore, it is crucial for women of childbearing age to ensure an adequate intake of folic acid to prevent such birth defects.
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Which of the following is a unique risk factor for substance misuse in individuals AFAB?
- A. Genetic predisposition
- B. High socioeconomic status
- C. Regular physical exercise
- D. History of trauma
Correct Answer: D
Rationale:
The nurse is assessing a client who reports vaginal bleeding at 20 weeks' gestation. What is the priority action?
- A. Assess the amount and color of bleeding.
- B. Place the client in a Trendelenburg position.
- C. Administer Rho(D) immune globulin.
- D. Perform a vaginal examination.
Correct Answer: A
Rationale: Assessing the bleeding provides critical information to determine the next steps and evaluate potential complications.
The nurse is caring for a client at 38 weeks' gestation reporting decreased fetal movement. What is the priority action?
- A. Perform a nonstress test.
- B. Instruct the client to drink orange juice.
- C. Schedule an ultrasound.
- D. Notify the healthcare provider immediately.
Correct Answer: A
Rationale: A nonstress test is the first step to assess fetal well-being in cases of decreased fetal movement.
A nurse is caring for a client who has hyperemesis gravidarum. Which of the following laboratory tests should the nurse anticipate?
- A. Urine Ketones
- B. Rapid plasma regain
- C. Prothrombin time
- D. Urine culture
Correct Answer: A
Rationale: Hyperemesis gravidarum is a severe form of nausea and vomiting during pregnancy that can lead to dehydration and electrolyte imbalances. One important laboratory test that the nurse should anticipate for a client with hyperemesis gravidarum is the urine ketones test. Ketones in the urine can indicate that the body is breaking down fat for energy instead of using glucose, which can occur during prolonged fasting or in conditions like hyperemesis gravidarum where there is severe vomiting leading to inadequate intake of nutrients. Monitoring urine ketones levels helps healthcare providers assess the severity of dehydration and metabolic derangement in these patients. It guides the management of fluid and electrolyte replacement to prevent complications like ketosis and metabolic acidosis.
A nurse is caring for a client who is in the transition phase of labor and reports a pain level of 7 on a scale of 0 to Which of the following actions should the nurse take?
- A. Instruct the client to use effleurage
- B. Apply counter pressure to the client sacral.
- C. Assist the client with patterned-paced breathing.
- D. Teach the client the technique of biofeedback.
Correct Answer: B
Rationale: In the transition phase of labor, the contractions are intense and the client may experience significant discomfort and pain. Applying counter pressure to the client's sacral area can help alleviate this pain by providing some relief and support. Counter pressure involves applying firm pressure with the palms or fists to the lower back or sacral area during contractions. This technique can help to relieve some of the pressure and discomfort experienced during contractions, making it a beneficial action for the nurse to take in this situation.