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A client at 20 weeks' gestation asks about fetal movements. What is the nurse's best response?
- A. Fetal movements are rarely felt before 24 weeks.
- B. You should feel strong, regular movements at this stage.
- C. You may feel fluttering movements, known as quickening.
- D. It is too early to feel any fetal movements.
Correct Answer: C
Rationale: The correct answer is C because quickening, described as fluttering movements, is typically felt by pregnant individuals around 18-20 weeks of gestation. This indicates fetal movement and is an important milestone in pregnancy. Choices A and D are incorrect as fetal movements can be felt as early as 18-20 weeks. Choice B is incorrect as feeling strong, regular movements is not expected until later in the pregnancy.
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A nurse is receiving laboratory results for a term newborn who is 24 hr. old. Which of the following results require intervention by the nurse?
- A. WBC count 10,000/mm3
- B. Platelets 180,000/mm3
- C. Hemoglobin 20g/dL
- D. Glucose 20 mg/dL
Correct Answer: D
Rationale: The correct answer is D because a glucose level of 20 mg/dL in a term newborn is significantly low and requires immediate intervention by the nurse. Low glucose levels can lead to hypoglycemia, which can be harmful to the newborn's brain development and overall health. A WBC count of 10,000/mm3 is within normal range for a newborn. Platelets of 180,000/mm3 and hemoglobin of 20g/dL are also within normal limits for a term newborn and do not require intervention.
A nurse is caring for a client who experienced a cesarean birth due to dysfunctional labor. The client states that she is disappointed that she did not have natural childbirth. Which of the following responses should the nurse make?
- A. "It sounds like you are feeling sad that things didn't go as planned."
- B. "At least you know you have a healthy baby."
- C. "Maybe next time you can have a vaginal delivery."
- D. "You can resume sexual relations sooner than if you had delivered vaginally."
Correct Answer: A
Rationale: Step 1: Empathy - The nurse acknowledges the client's feelings of disappointment, showing empathy and understanding.
Step 2: Validation - By stating "It sounds like you are feeling sad that things didn't go as planned," the nurse validates the client's emotions, making her feel heard and supported.
Step 3: Therapeutic Communication - This response encourages the client to express her feelings further, promoting open communication and trust in the nurse-client relationship.
Summary:
Choice B is incorrect as it dismisses the client's emotional concerns and focuses solely on the baby's health. Choice C is incorrect as it minimizes the client's current experience and may increase feelings of inadequacy. Choice D is incorrect as it is not relevant to the client's emotional needs and may be perceived as insensitive.
A client at 34 weeks' gestation reports decreased fetal movements. What should the nurse advise first?
- A. Drink a glass of juice and lie down.
- B. Come to the clinic immediately.
- C. Monitor fetal movements for 24 hours.
- D. Call the healthcare provider tomorrow.
Correct Answer: A
Rationale: The correct answer is A: Drink a glass of juice and lie down. This advice is based on the concept that consuming juice can stimulate fetal movements due to the increase in blood sugar levels. Lying down also helps the client focus on feeling the movements. This initial step is non-invasive and can potentially address the decreased fetal movements promptly. Choices B and D delay action, which can be dangerous if there is a significant issue with the baby. Choice C might lead to unnecessary waiting and potential risks if the fetus is in distress.
The nurse is educating an adolescent patient about Depo-Provera. Which statement should be included in this teaching session?
- A. You only need to come in every 5 months to get each injection.
- B. You may lose weight on this medication, so make sure to maintain a well-balanced diet.
- C. You may experience heavy bleeding or spotting monthly or none at all.
- D. You will not be able to start this medication until you have been pregnant at least once.
Correct Answer: C
Rationale: Correct Answer: C
Rationale:
1. Choice C is correct because it accurately informs the adolescent about the potential side effects of Depo-Provera, which include irregular bleeding patterns such as heavy bleeding or spotting, or even the absence of periods.
2. This information is crucial for the patient's understanding and preparedness while using the medication.
3. Choices A, B, and D are incorrect because:
- Choice A is inaccurate as Depo-Provera injections are typically required every 3 months, not 5 months.
- Choice B is irrelevant to Depo-Provera as weight changes are not a common side effect of this medication.
- Choice D is false as pregnancy history does not determine eligibility for Depo-Provera use.
After ovulation, what does the ruptured follicle in the ovary transform into?
- A. Corpus luteum
- B. Corpus cavernosum
- C. Corpus callosum
- D. Corpus albicans
Correct Answer: A
Rationale: After ovulation, the ruptured follicle transforms into the corpus luteum. This structure secretes hormones like progesterone to prepare the uterus for potential pregnancy. The other choices are incorrect because:
B: Corpus cavernosum is erectile tissue found in the penis.
C: Corpus callosum is a structure in the brain connecting the two hemispheres.
D: Corpus albicans is the remnant of the corpus luteum if pregnancy doesn't occur.