Nokea
A patient has just acknowledged that she is 20 weeks pregnant and confides to the nurse that she has a daily heroin habit. The nurse discusses treatment options for the patient. Which patient statement requires follow-up?
- A. "My plan is to visit the outpatient clinic daily for treatment."
- B. "will see my health care provider at least every 2 weeks."
- C. "My baby will not have to go through withdrawal when I take methadone."
- D. "With oral methadone, my baby and I are at decreased risk of infection."
Correct Answer: B
Rationale: The correct answer is B because seeing the healthcare provider every 2 weeks may not be frequent enough for monitoring a pregnant patient with a heroin habit. Regular monitoring is crucial for the well-being of both the mother and the baby. Option A shows a proactive approach for daily treatment, Option C is incorrect as methadone does not eliminate the risk of withdrawal in newborns, and Option D is incorrect as methadone does not reduce the risk of infection. Regular and close monitoring is essential in such cases to ensure the safety and health of both the mother and the baby.
You may also like to solve these questions
A client at 30 weeks' gestation is receiving magnesium sulfate for preterm labor. What assessment finding indicates magnesium toxicity?
- A. Deep tendon reflexes +3.
- B. Respiratory rate of 10 breaths per minute.
- C. Urine output of 40 mL/hour.
- D. Blood pressure of 120/80 mmHg.
Correct Answer: B
Rationale: The correct answer is B: Respiratory rate of 10 breaths per minute. Magnesium sulfate toxicity can lead to respiratory depression, resulting in a decreased respiratory rate. This is a critical sign of magnesium toxicity and should be addressed promptly.
Explanation for other choices:
A: Deep tendon reflexes +3 are actually a common finding in clients receiving magnesium sulfate due to its muscle relaxant effects.
C: Urine output of 40 mL/hour is within the normal range and does not indicate magnesium toxicity.
D: Blood pressure of 120/80 mmHg is also within the normal range and is not a sign of magnesium toxicity.
What question during a family assessment could the nurse ask to determine if the family has necessary resources?
- A. Do you enjoy spending time with your family?
- B. Do you have a group of friends, neighbors, or a church that helps you when you are ill?
- C. How often do you go to the store by yourself?
- D. Do your family members get along well?
Correct Answer: B
Rationale: The correct answer is B: "Do you have a group of friends, neighbors, or a church that helps you when you are ill?" This question assesses the family's support network and resources in times of need. It helps determine if the family has a social support system that can provide assistance during challenging situations. Options A, C, and D are incorrect as they do not directly address the availability of external resources for the family's well-being. Option A focuses on emotional aspects, C on independence, and D on family dynamics, which are not directly related to assessing resources.
The nurse is reviewing a prenatal client’s record. Which history finding increases the risk for preeclampsia?
- A. Advanced maternal age.
- B. History of gestational diabetes.
- C. First pregnancy.
- D. History of anemia.
Correct Answer: C
Rationale: The correct answer is C: First pregnancy. Preeclampsia is more common in first pregnancies due to the body's lack of adaptation to the pregnancy. In subsequent pregnancies, the body has already gone through the changes necessary for pregnancy, reducing the risk. Advanced maternal age (A) and history of gestational diabetes (B) are risk factors for other pregnancy complications but not specifically preeclampsia. History of anemia (D) is not directly linked to an increased risk of preeclampsia.
A preterm neonate develops physiologic jaundice and phototherapy is ordered. The nurse understands that this therapy:
- A. Activates the liver to dispose the bilirubin
- B. Breaks down the unconjugated bilirubin in the skin to conjugated form permitting excretion
- C. Activates Vit. K to facilitate excretion of the bilirubin
- D. Dissolves the bilirubin and allows it to be excreted from the skin
Correct Answer: B
Rationale: The correct answer is B because phototherapy works by breaking down unconjugated bilirubin in the skin to a water-soluble form, allowing it to be excreted from the body. This process does not activate the liver (choice A), nor does it activate Vitamin K (choice C) or dissolve the bilirubin for excretion from the skin (choice D). Phototherapy specifically targets the unconjugated bilirubin in the skin, converting it to a form that can be eliminated through the urine and stool.
A client at 35 weeks' gestation reports sharp abdominal pain and vaginal bleeding. What condition should the nurse suspect?
- A. Placenta previa.
- B. Abruptio placentae.
- C. Preterm labor.
- D. Chorioamnionitis.
Correct Answer: B
Rationale: The correct answer is B: Abruptio placentae. This condition presents with sharp abdominal pain and vaginal bleeding, typically occurring in the third trimester. It is caused by the premature separation of the placenta from the uterine wall. The pain is often severe due to the bleeding and can lead to fetal distress. Placenta previa (A) presents with painless vaginal bleeding, preterm labor (C) typically involves regular contractions and cervical changes, and chorioamnionitis (D) is characterized by fever and uterine tenderness.