Nokea
The nurse is assessing a client with a suspected diagnosis of abruptio placentae. Which finding is most indicative of this condition?
- A. Soft abdomen.
- B. Uterine tenderness and rigidity.
- C. Bright red, painless vaginal bleeding.
- D. Decreased fetal movements.
Correct Answer: B
Rationale: The correct answer is B: Uterine tenderness and rigidity. This finding is most indicative of abruptio placentae, which is the premature separation of the placenta from the uterine wall. Uterine tenderness and rigidity are classic signs due to the internal bleeding and blood accumulating between the placenta and uterine wall. This results in a tense and tender uterus.
A: Soft abdomen is incorrect as abruptio placentae typically presents with a firm, board-like abdomen due to uterine rigidity.
C: Bright red, painless vaginal bleeding is incorrect as abruptio placentae typically presents with dark red, painful vaginal bleeding.
D: Decreased fetal movements are incorrect as fetal distress can occur with abruptio placentae, but uterine tenderness and rigidity are more specific indicators of this condition.
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Upon delivery of the newborn, the nursing intervention that most promotes parental attachment is:
- A. Placing the infant under the radiant warmer
- B. Allowing the mother to rest immediately after delivery
- C. Placing the newborn on mother's chest and abdomen
- D. Taking the newborn to the nursery for the initial assessment
Correct Answer: C
Rationale: The correct answer is C: Placing the newborn on mother's chest and abdomen. This promotes parental attachment through skin-to-skin contact, facilitating bonding and emotional connection. It also helps regulate the baby's temperature and encourage breastfeeding. Placing the infant under the radiant warmer (A) may disrupt immediate bonding. Allowing the mother to rest (B) is important, but promoting attachment should be prioritized. Taking the newborn to the nursery (D) can delay the crucial bonding process.
Which nursing diagnoses may apply to the childbearing family with special needs? (Select all that apply.)
- A. Risk for spiritual distress
- B. Risk for injury
- C. Readiness for enhanced nutrition
- D. Ineffective breathing pattern
Correct Answer: B
Rationale: The correct answer is B: Risk for injury. This is because families with special needs in childbearing may face unique challenges leading to potential risks of injury, such as physical limitations or difficulties in providing adequate care. Option A is incorrect as spiritual distress is not directly related to physical safety. Option C is incorrect as enhanced nutrition readiness does not directly address safety concerns. Option D is incorrect as ineffective breathing pattern is a specific health issue not necessarily related to the family's safety. Therefore, B is the most appropriate nursing diagnosis for addressing safety concerns in the childbearing family with special needs.
Why was the Bradley Method originally introduced?
- A. as a novel approach to pregnancy where low-intervention, medication-free births were the goal
- B. as an education program that supported use of twilight birth
- C. as a system of supporting families wanting community birth
- D. as a program of education that focused on the importance of using a doula instead of a partner as a birth support
Correct Answer: A
Rationale: The correct answer is A: as a novel approach to pregnancy where low-intervention, medication-free births were the goal. The Bradley Method was introduced in the late 1940s by Dr. Robert Bradley with the aim of empowering women to have natural childbirth experiences without unnecessary medical interventions. This method promotes education and preparation for childbirth, emphasizing relaxation techniques, partner involvement, and natural pain management strategies. The other choices, B, C, and D, are incorrect because they do not align with the fundamental principles of the Bradley Method, which focuses on promoting low-intervention, medication-free births through education and empowerment of expectant parents.
What must instructions for use of nonoxynol-9 spermicide include?
- A. Nononxynol-9 used with barrier methods increases their efficacy.
- B. When spermicide is used with condoms, it will further decrease the risk of STIs.
- C. Remove excess spermicide from the vagina within 6 hours to reduce vaginal irritation.
- D. Place the spermicide close to the opening of the vagina for maximal effectiveness.
Correct Answer: C
Rationale: The correct answer, C, states that excess spermicide should be removed from the vagina within 6 hours to reduce vaginal irritation. This is important as leaving excess spermicide can lead to discomfort and irritation. It is a crucial instruction to ensure the user's comfort and safety.
Choice A is incorrect as nonoxynol-9 does not necessarily increase efficacy when used with barrier methods.
Choice B is incorrect because while using spermicide with condoms can reduce the risk of STIs, the statement does not specifically address the instructions for use.
Choice D is incorrect as placing the spermicide close to the vagina's opening does not guarantee maximal effectiveness and is not a critical instruction for safe use.
The nurse is assessing a client with hyperemesis gravidarum. What lab finding is most concerning?
- A. Elevated hematocrit.
- B. Decreased potassium.
- C. Increased white blood cell count.
- D. Low fasting blood glucose.
Correct Answer: B
Rationale: The correct answer is B: Decreased potassium. In hyperemesis gravidarum, excessive vomiting can lead to electrolyte imbalances, particularly hypokalemia. Potassium plays a crucial role in nerve and muscle function, so a low potassium level can result in serious complications such as cardiac arrhythmias. Elevated hematocrit (A) may indicate dehydration, but it is not as immediately concerning as potassium imbalance. Increased white blood cell count (C) may suggest infection but is not directly related to hyperemesis gravidarum. Low fasting blood glucose (D) can occur due to inadequate nutrient intake but is not the most concerning finding in this case.