Nokea
The nurse is assessing a client at 10 weeks' gestation. Which finding is expected?
- A. Quickening.
- B. Fetal heart tones by Doppler.
- C. Fundus at the level of the umbilicus.
- D. Presence of Braxton Hicks contractions.
Correct Answer: B
Rationale: Fetal heart tones can typically be detected by Doppler around 10 weeks' gestation.
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A patient had unprotected sex yesterday. She is interested in emergency contraception. The nurse knows that the patient has how long to take the medication for it to be effective?
- A. 24 hr
- B. 48 hr
- C. 3 days
- D. 5 days
Correct Answer: C
Rationale: Emergency contraception is most effective if taken within 3 days after unprotected sex. The sooner it is taken, the more effective it is. Choice A and B are incorrect because they are too short a time window for emergency contraception to be effective. Choice D is also incorrect because most emergency contraceptive pills are not effective after 5 days.
The nurse is assessing a client with suspected gestational diabetes. What is the most reliable diagnostic test?
- A. Random blood glucose test.
- B. Oral glucose tolerance test (OGTT).
- C. Fasting blood glucose test.
- D. Hemoglobin A1C.
Correct Answer: B
Rationale: The oral glucose tolerance test (OGTT) is the standard for diagnosing gestational diabetes.
A nurse is caring for a client who is 4 hr postpartum following a vaginal birth. The client has saturated a perineal pad within 10 min. Which of the following actions should the nurse take first
- A. Assess client's blood pressure.
- B. Assess the bladder for distention.
- C. Massage the client's fundus.
- D. Prepare to administer a prescribed oxytocic preparation.
Correct Answer: B
Rationale: The first action the nurse should take in this situation is to assess the bladder for distention. Postpartum hemorrhage can be caused by a distended bladder putting pressure on the uterus, preventing it from contracting effectively and leading to excessive bleeding. By assessing for bladder distention and ensuring the client empties her bladder, the nurse can help the uterus contract more efficiently and potentially reduce the bleeding. Assessing the other options such as blood pressure, massaging the fundus, and preparing to administer an oxytocic can be important interventions eventually, but addressing the bladder distention is the first priority in this case of excessive postpartum bleeding.
Which nursing intervention is most appropriate for a breastfeeding mother experiencing engorgement?
- A. Apply cold compresses to the breasts after feeding
- B. Limit breastfeeding to every 6 hours
- C. Use formula supplements to reduce milk supply
- D. Massage the breasts before feeding
Correct Answer: A
Rationale: Cold compresses reduce swelling and discomfort during engorgement.
A patient has just had a Mirena IUD inserted. What is the most important information for the nurse to include in the post-procedure instructions?
- A. You may experience severe cramping and should rest for several days.
- B. You should check the strings of the IUD regularly to ensure it is in place.
- C. You should avoid sexual activity for the first month after the insertion.
- D. The IUD will make your periods longer and heavier for the first 6 months.
Correct Answer: B
Rationale: The patient should be instructed to check the strings of the IUD regularly to ensure it remains in place. Choice A is not accurate because while cramping is common, rest is not necessarily required for several days. Choice C is not required; there is no need to avoid sexual activity unless there is an infection or other complication. Choice D is incorrect as Mirena typically reduces bleeding or makes periods lighter.