Nokea
The nurse is caring for a client in labor with a history of cesarean delivery. What is a priority assessment?
- A. Assess for signs of uterine rupture.
- B. Monitor maternal temperature hourly.
- C. Check for signs of preeclampsia.
- D. Assess for excessive fetal movement.
Correct Answer: A
Rationale: The correct answer is A: Assess for signs of uterine rupture. This is the priority assessment because a history of cesarean delivery puts the client at higher risk for uterine rupture during labor. Signs of uterine rupture include severe abdominal pain, abnormal fetal heart rate patterns, and vaginal bleeding. Early detection and intervention are crucial for the safety of both the mother and the baby. Monitoring maternal temperature (B) is important but not as critical as assessing for uterine rupture. Checking for signs of preeclampsia (C) is also important but not a priority in this specific scenario. Assessing for excessive fetal movement (D) is not a priority assessment in this case.
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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.
A 28-year-old patient has decided to use the patch contraception. The nurse is educating her on the best site to use. Where is the best place to put the patch? Select all that apply.
- A. Buttocks
- B. Neck
- C. Leg
- D. Arm
Correct Answer: B
Rationale: The correct answer is B: Neck. The patch contraception is most effective when applied to a clean, dry, and hairless area of the body. The neck is a suitable site because it is easily accessible, non-occlusive, and less likely to be affected by clothing friction. Placing the patch on the neck also helps avoid skin irritation and allows for optimal absorption of hormones.
Choice A: Buttocks - The buttocks may not be an ideal site as it can be covered by clothing and may not allow for proper adherence and absorption.
Choice C: Leg - The leg is not typically recommended as a site for the patch due to movement and friction from clothing that may affect patch adhesion and hormone absorption.
Choice D: Arm - While the arm is a possible site for the patch, it is not as ideal as the neck because it may be subject to more movement and rubbing against clothing, potentially affecting patch adherence and effectiveness.
While evaluating the reflexes of the newborn, the nurse notes that with a loud noise the newborn symmetrically abduct and extend his arms, his fingers fan out and forms a c with the thumb and forefinger. What does the nurse document?
- A. Positive Moro reflex
- B. Positive Babinski reflex
- C. Rooting reflex
- D. Tonic neck reflex
Correct Answer: A
Rationale: The correct answer is A: Positive Moro reflex. The Moro reflex is elicited by a sudden loud noise or a jarring movement. The newborn symmetrically abducts and extends their arms, followed by fanning out their fingers and forming a "C" shape with the thumb and forefinger. This reflex is an involuntary response that indicates the normal development of the newborn's nervous system. The other choices are incorrect because:
B: Positive Babinski reflex is elicited by stroking the sole of the foot, resulting in the toes fanning out and big toe dorsiflexing.
C: Rooting reflex is elicited by touching the newborn's cheek, causing them to turn their head towards the stimulus and open their mouth to seek food.
D: Tonic neck reflex is elicited by turning the newborn's head to one side, causing extension of the arm on that side and flexion of the opposite arm.
A postpartum client is getting ready to receive a Depo-Provera injection. Which statement by the client indicates that further teaching by the nurse is necessary?
- A. You will give this shot just like the rubella injection I received yesterday.
- B. I will watch my weight and try to exercise daily after receiving this injection.
- C. I will need to reschedule a follow-up appointment in 3 months.
- D. It might take me a year to get pregnant after receiving this type of birth control.
Correct Answer: A
Rationale: The correct answer is A because the client's comparison of receiving a Depo-Provera injection to a rubella injection is incorrect. Depo-Provera is a hormonal contraceptive injection that does not have the same administration process or purpose as a rubella vaccination. This indicates a lack of understanding about the medication.
Choice B is not the correct answer because it shows the client's awareness of the importance of weight management and exercise in conjunction with receiving the injection.
Choice C is not the correct answer because it demonstrates the client's understanding of the need for a follow-up appointment in 3 months which is necessary for monitoring and continuation of the contraceptive method.
Choice D is not the correct answer because it shows the client's understanding of the potential delay in fertility after discontinuing Depo-Provera, which is an important aspect of the contraceptive method that the client should be aware of.
The nurse is educating a pregnant client about foods high in iron. Which food should be recommended?
- A. Milk.
- B. Chicken.
- C. Spinach.
- D. Bananas.
Correct Answer: C
Rationale: The correct answer is C: Spinach.
1. Spinach is high in iron, which is important for pregnant women to prevent anemia.
2. Milk (A) does not contain a significant amount of iron.
3. Chicken (B) is a good source of protein but not as high in iron as spinach.
4. Bananas (D) are rich in potassium but not iron, making them a less suitable choice for iron supplementation during pregnancy.