Nokea
The nurse is caring for a client in labor who is HIV positive. Which nursing care should be included?
- A. Administering antiretroviral drugs as ordered
- B. Assisting the woman on a labor ball to help with natural descent of the fetus
- C. Handling the newborn with gloves until it receives its first bath
- D. Encouraging the mother to breastfeed soon after delivery
Correct Answer: A
Rationale: The correct answer is A: Administering antiretroviral drugs as ordered. This is crucial in preventing vertical transmission of HIV from mother to child during childbirth. Antiretroviral therapy reduces the viral load in the mother's blood and bodily fluids, decreasing the risk of transmission. Choice B is beneficial for labor progress but not directly related to HIV care. Choice C is unnecessary as HIV is not transmitted through skin contact. Choice D is contraindicated as breastfeeding can transmit HIV from mother to child.
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The nurse is caring for a client who is at 24 weeks gestation. Which assessment requires further intervention?
- A. Hemoglobin 11 and hematocrit 33
- B. Blood pressure of 130/80
- C. Patient has slight pedal swelling
- D. Urine dipstick for protein 3+
Correct Answer: D
Rationale: The correct answer is D because a urine dipstick reading of 3+ for protein indicates significant proteinuria, which can be a sign of preeclampsia in pregnancy. Preeclampsia poses serious risks to both the mother and the fetus, requiring immediate medical intervention.
Choice A: Hemoglobin and hematocrit levels within normal range for pregnancy.
Choice B: Blood pressure slightly elevated but not concerning at this gestational age.
Choice C: Slight pedal swelling is common in pregnancy and may not indicate a serious issue at this time.
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.
A nurse is monitoring a client with type 2 diabetes mellitus. Her blood work reveals a glycosylated hemoglobin (HbA1c) of 10%. The nurse knows this blood work indicates which of the following?
- A. A normal value indicating that the client is managing blood glucose control well
- B. A low value indicating that the client is not managing blood glucose control very well
- C. A high value indicating that the client is not managing blood glucose control very well
- D. The value does not offer information regarding client management of her disease
Correct Answer: C
Rationale: Rationale:
1. HbA1c reflects average blood glucose levels over the past 2-3 months.
2. A value of 10% indicates poor blood glucose control.
3. High HbA1c (like 10%) signifies uncontrolled diabetes.
4. Choice C is correct due to the high HbA1c value.
Summary:
A: Incorrect as 10% is high, not normal.
B: Incorrect, as 10% is high, not low.
D: Incorrect, as HbA1c does offer information regarding diabetes management.
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.
A nurse is caring for a client who is 32 weeks gestation who comes to the emergency department for painful bleeding. Which is the priority nursing assessment?
- A. Monitor for contractions
- B. Assess pain level
- C. Assess for hemorrhage
- D. Provide emotional support
Correct Answer: C
Rationale: The correct answer is C: Assess for hemorrhage. This is the priority assessment as the client is experiencing painful bleeding, indicating a potential hemorrhage which can be life-threatening. Assessing for hemorrhage will help identify the severity of the situation and guide immediate interventions. Monitoring for contractions (choice A) is important but assessing for hemorrhage takes precedence. Assessing pain level (choice B) is important but addressing the potential hemorrhage is more critical. Providing emotional support (choice D) is important but should come after addressing the urgent medical need of assessing for hemorrhage.