Nokea
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.
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A nurse is assessing a client who is 3 days postpartum and is breastfeeding. The nurse notes that the fundus is three fingerbreadths below the umbilicus, lochia rubra is moderate, and the breasts are hard and warm to palpation. Which of the following interpretations of these findings should the nurse make?
- A. The client is exhibiting early indications of mastitis.
- B. Additional interventions are not indicated at this time.
- C. Application of a heating pad to the breasts is indicated.
- D. The client should be advised to remove her nursing bra.
Correct Answer: B
Rationale: Correct Answer: B - Additional interventions are not indicated at this time.
Rationale:
1. Fundus location: Three fingerbreadths below the umbilicus is within normal range for 3 days postpartum.
2. Lochia rubra: Moderate lochia rubra is expected at this stage postpartum.
3. Breasts: Hard and warm breasts are indicative of engorgement, a common issue in breastfeeding mothers.
Summary:
A: Early indications of mastitis would include redness, warmth, and tenderness in the breasts, along with flu-like symptoms.
C: Application of a heating pad to the breasts can worsen engorgement and increase the risk of mastitis.
D: Removing a nursing bra may offer some relief for engorgement, but it is not the priority intervention at this time.
Nutrition is an integral part of the Bradley Method. What important nutrition advice is taught in this method?
- A. Only eat low-fat foods.
- B. Increase protein to 100 g per day.
- C. Do not eat dairy because it causes food allergies.
- D. Eat a low-protein diet.
Correct Answer: B
Rationale: The correct answer is B because the Bradley Method emphasizes the importance of increasing protein intake to support a healthy pregnancy. Protein is essential for fetal development and maternal health. It is recommended to consume around 100g of protein per day during pregnancy. Adequate protein intake helps in the growth of the baby and helps to maintain the health of the mother.
Explanation of why the other choices are incorrect:
A: Only eat low-fat foods - This is incorrect as fat is also important for a healthy pregnancy and should not be eliminated entirely.
C: Do not eat dairy because it causes food allergies - Dairy is a good source of calcium and other essential nutrients during pregnancy, so this advice is not recommended.
D: Eat a low-protein diet - This is incorrect as protein is crucial for the development of the baby and overall health during pregnancy.
A client at 34 weeks' gestation reports decreased fetal movements. What should the nurse advise first?
- A. Drink a glass of juice and lie down.
- B. Come to the clinic immediately.
- C. Monitor fetal movements for 24 hours.
- D. Call the healthcare provider tomorrow.
Correct Answer: A
Rationale: The correct answer is A: Drink a glass of juice and lie down. This advice is based on the concept that consuming juice can stimulate fetal movements due to the increase in blood sugar levels. Lying down also helps the client focus on feeling the movements. This initial step is non-invasive and can potentially address the decreased fetal movements promptly. Choices B and D delay action, which can be dangerous if there is a significant issue with the baby. Choice C might lead to unnecessary waiting and potential risks if the fetus is in distress.
The nurse is educating an adolescent patient about Depo-Provera. Which statement should be included in this teaching session?
- A. You only need to come in every 5 months to get each injection.
- B. You may lose weight on this medication, so make sure to maintain a well-balanced diet.
- C. You may experience heavy bleeding or spotting monthly or none at all.
- D. You will not be able to start this medication until you have been pregnant at least once.
Correct Answer: C
Rationale: Correct Answer: C
Rationale:
1. Choice C is correct because it accurately informs the adolescent about the potential side effects of Depo-Provera, which include irregular bleeding patterns such as heavy bleeding or spotting, or even the absence of periods.
2. This information is crucial for the patient's understanding and preparedness while using the medication.
3. Choices A, B, and D are incorrect because:
- Choice A is inaccurate as Depo-Provera injections are typically required every 3 months, not 5 months.
- Choice B is irrelevant to Depo-Provera as weight changes are not a common side effect of this medication.
- Choice D is false as pregnancy history does not determine eligibility for Depo-Provera use.
A client in the second stage of labor reports intense rectal pressure. What does this finding indicate?
- A. The baby is in a breech position.
- B. Cervical dilation is incomplete.
- C. The baby is descending into the birth canal.
- D. Labor contractions are ineffective.
Correct Answer: C
Rationale: Step 1: In the second stage of labor, the baby is descending into the birth canal for delivery.
Step 2: Intense rectal pressure is a common sensation as the baby moves down.
Step 3: This indicates progress in labor as the baby is descending.
Step 4: Choice A is incorrect as breech position presents differently.
Step 5: Choice B is incorrect as incomplete cervical dilation may not cause rectal pressure.
Step 6: Choice D is incorrect as effective labor contractions are needed for descent.