Nokea
The nurse is aware that a pre-term neonate may have a potential nutritional problem because of:
- A. Poor sucking reflex
- B. A decreased metabolic rate
- C. Decreased caloric requirement
- D. Increased absorption of nutrients
Correct Answer: A
Rationale: The correct answer is A: Poor sucking reflex. Pre-term neonates often have immature sucking reflexes, which can lead to difficulty in feeding and obtaining adequate nutrition. This can result in a potential nutritional problem. Option B is incorrect because pre-term neonates actually have an increased metabolic rate to support their growth and development. Option C is incorrect as pre-term neonates have increased caloric requirements due to their rapid growth. Option D is incorrect as pre-term neonates typically have decreased absorption of nutrients due to an immature gastrointestinal system.
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A woman is 16 weeks pregnant and she had cramping backache and mild bleeding for the past 3 days. The HCP determines she is dilated 2cm, 10% effaced, membranes intact. She's crying and saying to the nurse is my baby going to be okay? In addition to acknowledging the patient's fear the nurse should also say:
- A. Your cervix has begun to dilate, this is a serious sign, we will continue to monitor you and the baby for now
- B. I really can't say but when your physicians arrive, I'll ask her talk to you about it
- C. You baby will be fine, we will start an IV and get this stopped in no time at all
- D. You are going to miscarry, but you should be relieved because most miscarriages are the result of abnormalities in the fetus
Correct Answer: A
Rationale: Step 1: Acknowledge the patient's fear and anxiety.
Step 2: Provide a clear and honest response regarding the situation.
Step 3: Explain the significance of cervical dilation at 16 weeks.
Step 4: Assure the patient that they will be closely monitored.
Step 5: Offer support and comfort to the patient.
Summary:
Choice A is correct because it addresses the patient's concerns, acknowledges the seriousness of the situation, provides information about cervical dilation, and reassures the patient about monitoring. Choices B, C, and D are incorrect because they do not provide accurate information or address the situation appropriately, which could further distress the patient.
A client at 12 weeks' gestation asks about the purpose of nuchal translucency testing. What is the nurse's best response?
- A. It screens for fetal anemia.
- B. It detects neural tube defects.
- C. It screens for chromosomal abnormalities.
- D. It confirms gestational age.
Correct Answer: C
Rationale: The correct answer is C because nuchal translucency testing is primarily used to screen for chromosomal abnormalities, such as Down syndrome, in the fetus. This test measures the thickness of the fluid-filled space at the back of the baby's neck. It is typically done between 11 and 14 weeks of pregnancy. This testing helps to assess the risk of genetic conditions in the fetus. Option A is incorrect because nuchal translucency testing does not screen for fetal anemia. Option B is incorrect because it does not detect neural tube defects. Option D is incorrect because it does not confirm gestational age.
The nurse is assessing a client in the third trimester with suspected gestational diabetes. What symptom is most concerning?
- A. Increased thirst and urination.
- B. Fasting blood glucose of 100 mg/dL.
- C. Weight gain of 1 pound in a week.
- D. Proteinuria of +1.
Correct Answer: A
Rationale: The correct answer is A: Increased thirst and urination. In gestational diabetes, increased thirst and urination can indicate uncontrolled blood sugar levels, which can harm the fetus. This symptom suggests hyperglycemia and requires immediate intervention.
B: Fasting blood glucose of 100 mg/dL is within the normal range for pregnancy and not concerning.
C: Weight gain of 1 pound in a week can be normal in the third trimester and not specific to gestational diabetes.
D: Proteinuria of +1 is more concerning for preeclampsia rather than gestational diabetes.
A client is to receive Pergonal (menotropins) injections for infertility prior to in-vitro fertilization. Which of the following is the expected action of this medication?
- A. Stimulation of ovulation
- B. Prolongation of the luteal phase
- C. Promotion of cervical mucus production
- D. Suppression of menstruation fertilization. Which of the following is the expected action of this medication?
Correct Answer: A
Rationale: The correct answer is A: Stimulation of ovulation. Pergonal contains menotropins, which are hormones that stimulate the ovaries to produce eggs. During in-vitro fertilization, the goal is to retrieve multiple eggs for fertilization, making ovulation stimulation crucial.
Explanation for incorrect choices:
B: Prolongation of the luteal phase - Pergonal does not affect the luteal phase, which occurs after ovulation.
C: Promotion of cervical mucus production - Pergonal does not directly influence cervical mucus production.
D: Suppression of menstruation - Pergonal does not suppress menstruation but rather induces ovulation.
A client at 20 weeks' gestation reports leg cramps. What recommendation should the nurse provide?
- A. Increase potassium intake.
- B. Stretch the legs before bed.
- C. Drink fluids during meals.
- D. Reduce physical activity.
Correct Answer: B
Rationale: The correct answer is B: Stretch the legs before bed. Leg cramps during pregnancy are common due to increased weight and pressure on blood vessels. Stretching before bed helps prevent cramps by improving circulation and muscle relaxation. Increasing potassium intake (choice A) can help with muscle function but is not the primary intervention for leg cramps. Drinking fluids during meals (choice C) is important for hydration but does not directly address leg cramps. Reducing physical activity (choice D) may worsen circulation and muscle cramps.