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The nurse is monitoring a woman with signs and symptoms of preterm labor. Which does the nurse include in the teaching plan?
- A. Importance of performing daily fetal movement counts
- B. Need to refrain from putting any objects in the vagina
- C. Need to take a daily stool softener
- D. The need to decrease fluid intake
Correct Answer: B
Rationale: The correct answer is B: Need to refrain from putting any objects in the vagina. This is because introducing objects into the vagina can potentially trigger preterm labor by causing infections or irritating the cervix. It is important to maintain vaginal hygiene to prevent complications.
Choice A is incorrect as monitoring fetal movements is important but not directly related to preventing preterm labor. Choice C is incorrect as taking a stool softener is unrelated to preterm labor. Choice D is incorrect as decreasing fluid intake is not recommended and may lead to dehydration, which is detrimental during pregnancy.
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The labor and delivery nurse reviews a client’s prenatal records and notes that the client had a positive GBS culture at 27 weeks gestation. Based on current guidelines, what is the recommended plan?
- A. Send a GBS to the laboratory immediately
- B. Prepare to administer penicillin prophylactically
- C. Determine if a follow-up culture was done at 38 weeks gestation
- D. Determine if the patient received antibiotics for the positive strep
Correct Answer: B
Rationale: The correct answer is B: Prepare to administer penicillin prophylactically. This is recommended by current guidelines for clients with a positive GBS culture at 27 weeks gestation to prevent transmission to the newborn during delivery. Administering penicillin prophylactically during labor significantly reduces the risk of early-onset GBS disease in newborns.
A: Sending a GBS to the laboratory immediately is not necessary as the client's GBS status is already known.
C: Checking for a follow-up culture at 38 weeks gestation is not the recommended plan based on current guidelines.
D: Determining if the patient received antibiotics for the positive strep is not the immediate action needed; prophylactic antibiotics during labor are the standard of care.
The nurse is caring for a patient who is receiving magnesium sulfate for pre-eclampsia. Which assessments will be of the highest priority?
- A. Assessing lung sounds
- B. Assessing blood sugar level
- C. Encouraging fluid intake
- D. Assessing for pitting edema
Correct Answer: A
Rationale: The correct answer is A: Assessing lung sounds. This is of highest priority because magnesium sulfate can lead to respiratory depression. Assessing lung sounds helps monitor for signs of respiratory distress, such as decreased breath sounds or crackles. Assessing blood sugar level (B) is important but not as urgent as respiratory status. Encouraging fluid intake (C) is important for hydration but not as critical as respiratory assessment. Assessing for pitting edema (D) is relevant for monitoring fluid retention but not as immediate as assessing lung sounds for respiratory compromise.
The labor and delivery nurse reviews a client’s prenatal records and notes that the client had a positive GBS culture at 27 weeks gestation. Based on current guidelines, what is the recommended plan?
- A. Send a GBS to the laboratory immediately
- B. Prepare to administer penicillin prophylactically
- C. Determine if a follow-up culture was done at 38 weeks gestation
- D. Determine if the patient received antibiotics for the positive strep
Correct Answer: B
Rationale: The correct answer is B: Prepare to administer penicillin prophylactically. This is the recommended plan because current guidelines suggest administering intrapartum prophylaxis with penicillin for GBS-positive pregnant women to prevent neonatal GBS disease. Choice A is incorrect because sending a GBS to the laboratory immediately is unnecessary since the previous positive culture result is already known. Choice C is incorrect because follow-up cultures are not routinely recommended at 38 weeks gestation. Choice D is incorrect because determining if the patient received antibiotics for the positive strep does not address the need for intrapartum prophylaxis specifically with penicillin.
The nurse is providing discharge instructions to a 28-year-old client who received methotrexate for an ectopic pregnancy. Which should the discharge instructions include?
- A. Make sure to take folic acid
- B. Make an appointment to see her provider in 6 weeks
- C. Flush the toilet twice after she urinates for the next 24 hours
- D. Resume all activity in 48 hours
Correct Answer: C
Rationale: The correct answer is C. Methotrexate is a chemotherapy agent that can be harmful to others if not properly eliminated from the body. Instructing the client to flush the toilet twice after urination for the next 24 hours helps to reduce the risk of exposing others to the medication through urine. This precaution is important to prevent potential harm to others.
Choices A, B, and D are incorrect:
A: Taking folic acid is generally recommended to reduce side effects of methotrexate but is not directly related to the safety of others.
B: While follow-up appointments are important, the immediate safety concern of methotrexate elimination is more critical.
D: Resuming all activity in 48 hours may not be appropriate depending on the individual's response to methotrexate and their recovery process.
The nurse is monitoring a woman with signs and symptoms of preterm labor. Which does the nurse include in the teaching plan?
- A. Importance of performing daily fetal movement counts
- B. Need to refrain from putting any objects in the vagina
- C. Need to take a daily stool softener
- D. The need to decrease fluid intake
Correct Answer: B
Rationale: The correct answer is B: Need to refrain from putting any objects in the vagina. This is important to prevent irritating the cervix and potentially triggering preterm labor. Putting objects in the vagina can introduce bacteria, leading to infection, which can increase the risk of preterm labor. Option A is important for monitoring fetal well-being but not directly related to preventing preterm labor. Option C is not relevant to preterm labor. Option D is incorrect as hydration is important in preventing preterm labor.