Nokea
The nurse correctly explains to the group that the most important condition related to frequent urination during pregnancy is related to what factor?
- A. Loss of bladder tone in the mother
- B. The presence of a urinary tract infection
- C. The enlarging uterus exerting pressure on the bladder
- D. The growing fetus excreting increased amounts of waste
Correct Answer: C
Rationale: The enlarging uterus presses on the bladder, causing frequent urination, especially in early and late pregnancy.
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The nurse is caring for the antepartum client with a velamentous cord insertion. The client asks what symptom she would most likely experience first if one of the vessels should tear. The nurse should respond that she would most likely experience which symptom first?
- A. Vaginal bleeding
- B. Abdominal cramping
- C. Uterine contractions
- D. Placental abruption
Correct Answer: A
Rationale: In a velamentous cord insertion, vessels of the cord divide some distance from the placenta in the placental membrane. Thus, the most likely first symptom would be vaginal bleeding. Abdominal cramping is unlikely to occur; velamentous cord insertion is not related to uterine activity. Contractions are unlikely to occur; velamentous cord insertion is not related to uterine activity. An abruption, when the placenta comes off the uterine wall, results in severe abdominal pain.
The nurse is reviewing the medication history of the client during preconception counseling. The client reports taking isotretinoin for acne. Which is the nurse’s best response?
- A. “Stop taking isotretinoin now! It can cause serious birth defects if you become pregnant.”
- B. “You need to be on some type of birth control right now. Getting pregnant is not an option.”
- C. “Talk with your HCP about changing isotretinoin before you consider becoming pregnant.”
- D. “Once you are off of isotretinoin for treating acne, you can then safely become pregnant.”
Correct Answer: C
Rationale: The best response is to have the client consult her HCP so another medication can be prescribed. This response indicates that isotretinoin (Accutane) is not safe but that alternative medications can be prescribed. Responding to the client emphatically can create anxiety and fear. Telling the client that getting pregnant is not an option is a paternal response and does not facilitate open communication. Clients must wait one month after cessation of isotretinoin before becoming pregnant.
Which action by the nurse best ensures that an accurate fetal heart rate is obtained?
- A. Assess the fetal heart rate when the client is lying on her right side.
- B. Assess the fetal heart rate when the client reports fetal movement.
- C. Assess the fetal heart rate between Braxton Hicks contractions.
- D. Assess the maternal pulse and fetal heart rate, and compare the two.
Correct Answer: D
Rationale: Comparing maternal pulse with fetal heart rate ensures the nurse is not mistaking the maternal pulse for the fetal heartbeat.
The nurse correctly explains to the group that the discomfort associated with varicose veins is relieved by which activity?
- A. Resting with the feet in a dependent position
- B. Sitting for periods of time when possible
- C. Putting on calf-length, elastic-top hose
- D. Moving around after standing in one position
Correct Answer: C
Rationale: Elastic-top hose improves venous return, reducing discomfort from varicose veins, unlike dependent positioning or sitting.
The oncoming shift nurse assesses the fundus of the postpartum client 6 hours after a vaginal birth and finds that it is firm. When the nurse then assists the client out of bed for the first time, blood begins to run down the client’s leg. Which action by the nurse in response to the client’s bleeding is correct?
- A. Explain that extra bleeding can occur with initial standing
- B. Immediately assist the client back into bed
- C. Push the emergency call light in the room
- D. Call the HCP to report this increased bleeding
Correct Answer: A
Rationale: Lochia normally pools in the vagina when the postpartum client remains in a recumbent position for any length of time. When the client then stands, gravity causes the blood to flow out. As long as the nurse knows the fundus is firm and not bleeding, a simple explanation to the client is all that is required. There is no reason to return the client to bed; the fundus is firm. There is no reason to push the emergency call light. Increased bleeding is an expected response when standing for the first time. There is no reason to call the HCP.