Nokea
A nurse is completing a health history for a client who is at 6-week gestation. The client informs the nurse that she smokes one park of cigarettes per day. The nurse should advise the client that smoking places the client9s newborn at risk for what complication?
- A. Hearing loss
- B. Intrauterine growth restriction
- C. Type 1 diabetes mellitus
- D. Congenital heart defects
Correct Answer: B
Rationale: The correct answer is B: Intrauterine growth restriction (IUGR). Smoking during pregnancy can restrict blood flow to the fetus, leading to inadequate oxygen and nutrients, resulting in IUGR. This can lead to low birth weight and potential health complications for the newborn. Hearing loss (A) is not directly associated with smoking during pregnancy. Type 1 diabetes mellitus (C) is an autoimmune condition not caused by maternal smoking. Congenital heart defects (D) can be a risk with smoking during pregnancy, but the most direct risk is IUGR.
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The nurse is preparing a client for an amniocentesis. What is the priority nursing action before the procedure?
- A. Administer IV fluids.
- B. Obtain baseline vital signs.
- C. Ensure informed consent is signed.
- D. Position the client in the Trendelenburg position.
Correct Answer: C
Rationale: The correct answer is C: Ensure informed consent is signed. Before any invasive procedure like an amniocentesis, it is essential to ensure that the client has full understanding of the risks, benefits, and alternatives. This is crucial for autonomy and ethical practice. Administering IV fluids (choice A) is not a priority before an amniocentesis. Obtaining baseline vital signs (choice B) is important but not the priority over informed consent. Positioning the client in the Trendelenburg position (choice D) is not necessary for an amniocentesis procedure.
A woman is 16 weeks pregnant and she had cramping backache and mild bleeding for the past 3 days. The HCP determines she is dilated 2cm, 10% effaced, membranes intact. She's crying and saying to the nurse is my baby going to be okay? In addition to acknowledging the patient's fear the nurse should also say:
- A. Your cervix has begun to dilate, this is a serious sign, we will continue to monitor you and the baby for now
- B. I really can't say but when your physicians arrive, I'll ask her talk to you about it
- C. You baby will be fine, we will start an IV and get this stopped in no time at all
- D. You are going to miscarry, but you should be relieved because most miscarriages are the result of abnormalities in the fetus
Correct Answer: A
Rationale: Step 1: Acknowledge the patient's fear and anxiety.
Step 2: Provide a clear and honest response regarding the situation.
Step 3: Explain the significance of cervical dilation at 16 weeks.
Step 4: Assure the patient that they will be closely monitored.
Step 5: Offer support and comfort to the patient.
Summary:
Choice A is correct because it addresses the patient's concerns, acknowledges the seriousness of the situation, provides information about cervical dilation, and reassures the patient about monitoring. Choices B, C, and D are incorrect because they do not provide accurate information or address the situation appropriately, which could further distress the patient.
A client at 20 weeks' gestation asks about fetal movements. What is the nurse's best response?
- A. Fetal movements are rarely felt before 24 weeks.
- B. You should feel strong, regular movements at this stage.
- C. You may feel fluttering movements, known as quickening.
- D. It is too early to feel any fetal movements.
Correct Answer: C
Rationale: The correct answer is C because quickening, described as fluttering movements, is typically felt by pregnant individuals around 18-20 weeks of gestation. This indicates fetal movement and is an important milestone in pregnancy. Choices A and D are incorrect as fetal movements can be felt as early as 18-20 weeks. Choice B is incorrect as feeling strong, regular movements is not expected until later in the pregnancy.
The nurse is performing a prenatal assessment. What finding is considered a positive sign of pregnancy?
- A. Positive pregnancy test.
- B. Auscultation of fetal heart tones.
- C. Hegar's sign.
- D. Chadwick's sign.
Correct Answer: B
Rationale: The correct answer is B, auscultation of fetal heart tones, because it is a definitive sign of pregnancy indicating the presence of a fetus. This can be heard around 10-12 weeks of gestation using a Doppler device. It is a positive sign as it directly confirms the existence of a developing fetus.
A: A positive pregnancy test is a probable sign and can indicate pregnancy but is not definitive.
C: Hegar's sign is a probable sign characterized by softening of the lower uterine segment, not specific to pregnancy.
D: Chadwick's sign is a probable sign of pregnancy indicated by bluish discoloration of the cervix, vagina, and labia, not a definitive sign of pregnancy.
The nurse is assessing a client with suspected preterm labor. Which finding confirms the diagnosis?
- A. Regular uterine contractions every 10 minutes.
- B. Cervical dilation of 3 cm.
- C. Lower back pain and cramping.
- D. Positive fetal fibronectin test.
Correct Answer: B
Rationale: The correct answer is B: Cervical dilation of 3 cm. This finding confirms preterm labor as it indicates cervical changes associated with labor progression. Regular uterine contractions every 10 minutes (choice A) may suggest labor but alone doesn't confirm preterm labor. Lower back pain and cramping (choice C) are common symptoms but not specific to preterm labor. A positive fetal fibronectin test (choice D) may indicate an increased risk of preterm labor but doesn't confirm the diagnosis definitively.