Nokea
The nurse is educating a client about iron supplements during pregnancy. Which statement indicates understanding?
- A. I should take the supplement with milk to improve absorption.
- B. I should take the supplement with orange juice to improve absorption.
- C. I can stop taking the supplement when I feel better.
- D. I should only take the supplement if I feel fatigued.
Correct Answer: B
Rationale: Vitamin C in orange juice enhances iron absorption, improving its efficacy.
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The nurse is performing an assessment of a client who is scheduled for a cesarean delivery at 39 weeks of gestation. Which assessment finding indicates the need to contact the health care provider (HCP)?
- A. Hemoglobin of 11 g/dL (110 mmol/L)
- B. Fetal heart rate of 180 beats/minute
- C. Maternal pulse rate of 85 beats/minute
- D. White blood cell count of 12,000 mm3 (12.0 × 109/L)
Correct Answer: B
Rationale: A fetal heart rate of 180 bpm may indicate fetal distress and warrants immediate HCP notification.
A client has just given birth, during labor the fetus was in brow presentation, but after prolonged laboring the fetus convert to occiput presentation and was delivered vaginally by vacuum extraction
- A. What should be explained
- B. Molding of the head will subside in a few days
- C. Meconium aspiration
- D. Infant will have prophylactic antibiotic
Correct Answer: A
Rationale: In this scenario, it is important to explain to the client what happened during labor and delivery. It is essential to communicate that the fetus was in a brow presentation initially, which can sometimes lead to complications during labor. However, the fetus converted to occiput presentation and was successfully delivered vaginally with the help of vacuum extraction. Providing this information to the client helps in ensuring transparency and understanding of the events that occurred, addressing any concerns or questions they may have about the delivery process.
The nurse is caring for a client in the second stage of labor. What finding indicates that birth is imminent?
- A. Cervix is fully dilated.
- B. Contractions every 2 minutes.
- C. Fetal heart rate of 140 beats/minute.
- D. Crowning is observed.
Correct Answer: D
Rationale: Crowning, or the appearance of the fetal head at the vaginal opening, indicates that birth is imminent.
A client at 16 weeks' gestation asks about the purpose of a maternal serum alpha-fetoprotein (MSAFP) test. What is the nurse's best response?
- A. It screens for chromosomal abnormalities.
- B. It detects neural tube defects.
- C. It confirms the gestational age of the baby.
- D. It identifies the baby's sex.
Correct Answer: B
Rationale: The MSAFP test is used to screen for neural tube defects such as spina bifida.
A nurse is leading a discussion about contraception with a group of 14-year-old-client. After the presentation a client asks the client which method would be best for her to use. How should the nurse respond?
- A. "Because of your age, i think that a barrier method would be the best choice."
- B. "Before i can help you, i need to know more about your sexual activity."
- C. "A provider can help you with that after a physical examination."
- D. "You are so young. Are you ready for the responsibilities of a sexual relationship?"
Correct Answer: B
Rationale: The appropriate response for the nurse to provide to the 14-year-old client who asks the best contraception method for her is to gather more information about her sexual activity first. This approach is essential in understanding the client's individual needs and situation before recommending a suitable contraceptive method. It allows the nurse to offer personalized and accurate advice based on the client's specific circumstances, rather than making assumptions or providing generic recommendations. By starting with a discussion about the client's sexual activity, the nurse can ensure that the advice given is tailored to the client's needs and preferences, promoting informed decision-making and effective contraceptive use.