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The nurse is caring for a client with gestational hypertension. What symptom should be reported immediately?
- A. Headache unrelieved by acetaminophen.
- B. Slight swelling of the hands.
- C. Mild nausea after eating.
- D. Fatigue at the end of the day.
Correct Answer: A
Rationale: Headache unrelieved by medication may indicate worsening gestational hypertension or preeclampsia.
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The patient's family history includes sickle cell disease. The patient's partner also has sickle cell disease in the family history. What type of test should the nurse discuss with the couple due to their family history?
- A. carrier screening for both parents
- B. ultrasound at 6 weeks’ gestation
- C. glucose screening for both parents
- D. thyroid testing
Correct Answer: A
Rationale:
The nurse is monitoring a laboring client with oxytocin infusion. What finding requires immediate intervention?
- A. Contractions lasting 60 seconds.
- B. Contractions every 2 minutes.
- C. Fetal heart rate of 100 beats/minute.
- D. Client reports back pain.
Correct Answer: C
Rationale: A fetal heart rate of 100 bpm indicates bradycardia, requiring immediate intervention to ensure fetal well-being.
The nurse is caring for a client with preeclampsia. What is the most important assessment?
- A. Daily weight.
- B. Urine protein levels.
- C. Fetal heart rate.
- D. Blood pressure.
Correct Answer: D
Rationale: Blood pressure monitoring is critical to prevent complications such as eclampsia and placental issues in preeclampsia.
The nurse is discussing contraceptive options with a patient who states they want to become pregnant in 1 year. Which contraception choice would be appropriate for them? Select all that apply.
- A. progestin-only contraceptive injections like DMPA
- B. progestin-only oral contraceptive pills
- C. fertility awareness methods
- D. COCs
Correct Answer: C
Rationale: Fertility awareness methods involve tracking a woman's menstrual cycle to identify the fertile window when pregnancy is most likely to occur. This method does not interfere with future fertility and can be used by individuals who plan to become pregnant in the near future. Since the patient expressed a desire to conceive in one year, fertility awareness methods would be the most appropriate contraceptive option for them.
Which intervention is most appropriate for a mother with mastitis?
- A. Advise the mother to stop breastfeeding temporarily
- B. Encourage continued breastfeeding
- C. Apply cold compresses to the affected breast
- D. Refer the mother to a lactation consultant
Correct Answer: B
Rationale: Continuing breastfeeding helps resolve mastitis by clearing milk ducts.