Nokea
The nurse is assessing a client in the third trimester who reports headaches and blurred vision. What is the priority nursing action?
- A. Check the client's blood pressure.
- B. Assess fetal heart rate.
- C. Administer acetaminophen as prescribed.
- D. Encourage the client to lie down and rest.
Correct Answer: A
Rationale: Headaches and blurred vision can be symptoms of preeclampsia, making blood pressure assessment a priority.
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Which client would be at greatest risk for developing
- A. Thick breast cancer?
- B. Wet/slippery with egg white consistency
- C. Client who had her first baby at the age of 24
- D. Client who did not breastfeed
Correct Answer: D
Rationale: Not breastfeeding has been identified as a risk factor for developing breast cancer. Breastfeeding has been shown to have a protective effect against breast cancer due to its impact on hormonal levels and breast tissue changes that occur during lactation. Therefore, compared to other options, the client who did not breastfeed would be at greater risk for developing breast cancer.
The nurse is caring for a client with gestational diabetes. What complication should the nurse monitor for during labor?
- A. Placental abruption.
- B. Macrosomia.
- C. Preterm labor.
- D. Postpartum hemorrhage.
Correct Answer: B
Rationale: Macrosomia is a common complication of gestational diabetes, increasing the risk of delivery challenges.
What is the priority nursing action when shoulder dystocia is encountered during delivery?
- A. Apply fundal pressure
- B. Call for additional assistance
- C. Perform the McRoberts maneuver
- D. Encourage the mother to push harder
Correct Answer: C
Rationale: The McRoberts maneuver widens the pelvic outlet for delivery.
A 17-year-old patient receives emergency contraception in a clinic. What is the priority nursing education for this patient at this time?
- A. The need for further contraception because the emergency contraception is only temporary
- B. The need to protect herself from STIs
- C. The need to come back in for a pelvic examination 1 week after taking the medication
- D. The need to drink plenty of fluids while on this medication
Correct Answer: A
Rationale: The patient should be informed that emergency contraception is a temporary measure and they need a long-term contraceptive plan. Choice B, while important for overall sexual health, is not the priority immediately after administering emergency contraception. Choice C is not necessary unless there are complications or a follow-up consultation is needed. Choice D about drinking fluids is unnecessary and not specific to the effectiveness of emergency contraception.
A pregnant client asks why she needs to avoid lying on her back during the third trimester. What is the best response?
- A. Lying on your back increases the risk of preterm labor.
- B. Lying on your back can reduce blood flow to your baby.
- C. Lying on your back causes increased fetal movements.
- D. Lying on your back is uncomfortable for most women.
Correct Answer: B
Rationale: Supine positioning can compress the vena cava, reducing blood flow to the fetus.