Nokea
The nurse correctly assists the client into which position?
- A. Lithotomy
- B. Prone
- C. Sims'
- D. Trendelenburg's
Correct Answer: A
Rationale: The lithotomy position, with legs elevated and apart, is standard for pelvic examinations to provide access to the pelvic area.
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Which nursing instruction is most appropriate regarding the relief of itchy skin during pregnancy?
- A. Take a hot bath daily.
- B. Increase fluid intake.
- C. Add a daily vitamin C tablet to the diet.
- D. Take diphenhydramine (Benadryl) twice per day.
Correct Answer: B
Rationale: Increasing fluid intake hydrates the skin, reducing itchiness, while hot baths or antihistamines may worsen symptoms or require medical approval.
The nurse instructs the client to report which newborn symptom immediately?
- A. Mild jaundice on day 3
- B. Inability to suck or feed
- C. Occasional sneezing
- D. Soft spot on head
Correct Answer: B
Rationale: Inability to suck or feed is a serious symptom that may indicate neurological or health issues, requiring immediate reporting.
Which response by the nurse is most appropriate?
- A. A weight gain of about 10 pounds is recommended during pregnancy.
- B. Your weight gain depends on the amount of food that you eat.
- C. It's normal for adolescent girls to be worried about weight gain.
- D. You're average weight gain during pregnancy is between 25 and 35 pounds.
Correct Answer: D
Rationale: The average weight gain of 25-35 pounds is appropriate for a teenager with normal prepregnancy weight, addressing her concerns.
To best enhance absorption of the iron supplement, which foods should the nurse recommend the client increase in her diet? Select all that apply.
- A. Oranges
- B. Potatoes
- C. Bananas
- D. Broccoli
- E. Whole milk
- F. Carrots
Correct Answer: A,D
Rationale: Oranges and broccoli are rich in vitamin C, which enhances iron absorption, unlike the other options.
The 42-year-old client who had a partial hydatidiform molar pregnancy 3 months ago asks the nurse whether she and her husband can try conceiving again. Which response by the nurse is incorrect and warrants follow-up action by the observing nurse manager?
- A. “You will need serial levels of beta human chorionic gonadotropin (BHCG) drawn.”
- B. “You cannot conceive ever again because of your risk of choriocarcinoma.”
- C. “You should not become pregnant yet for 6 to 12 months.”
- D. “Your risk of another hydatidiform molar pregnancy is low.”
Correct Answer: B
Rationale: Women who have had a molar pregnancy can conceive again once their BHCG levels are normal and remain normal for a certain time period, usually 6 to 12 months. This response by the nurse is incorrect and should be followed up by the observing nurse manager. Because of the risk of choriocarcinoma, serial serum BHCG testing is completed after a hydatidiform molar pregnancy. Because the client will undergo serial serum BHCG testing after a hydatidiform molar pregnancy, she should not get pregnant for 6 to 12 months until testing is completed and it is confirmed that she does not have a malignancy. Couples with a past history of molar pregnancy have the same statistical chance of conceiving again and having a normal pregnancy as those without.