Nokea
The nurse is assessing a client with suspected chorioamnionitis. What is the priority nursing assessment?
- A. Assess for foul-smelling vaginal discharge.
- B. Monitor maternal blood pressure.
- C. Evaluate fetal heart rate.
- D. Check maternal glucose levels.
Correct Answer: C
Rationale: The correct answer is C: Evaluate fetal heart rate. In chorioamnionitis, fetal distress can occur due to infection and inflammation of the fetal membranes. Monitoring fetal heart rate is crucial to assess the well-being of the baby. Assessing for foul-smelling discharge (A) is important but not the priority. Monitoring maternal blood pressure (B) and checking glucose levels (D) are relevant assessments but do not address the immediate risk of fetal distress in chorioamnionitis.
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A client at 12 weeks' gestation reports nausea and vomiting. What is the best dietary advice?
- A. Eat three large meals a day.
- B. Drink fluids with meals.
- C. Consume small, frequent meals throughout the day.
- D. Avoid protein-rich foods.
Correct Answer: C
Rationale: The correct answer is C: Consume small, frequent meals throughout the day. This advice helps manage nausea and vomiting during pregnancy by preventing an empty stomach, which can worsen symptoms. Eating small, frequent meals helps stabilize blood sugar levels and provides a steady source of nutrients for the developing fetus. It also reduces the likelihood of triggering nausea by avoiding large meals. Drinking fluids with meals (choice B) may exacerbate symptoms by filling up the stomach too quickly. Eating three large meals a day (choice A) can lead to overeating and may worsen nausea. Avoiding protein-rich foods (choice D) is not recommended as protein is essential for fetal development and overall health during pregnancy.
The nurse is assessing a client in the second stage of labor. What is the nurse's priority assessment?
- A. Frequency of contractions.
- B. Cervical dilation.
- C. Fetal descent and position.
- D. Intensity of contractions.
Correct Answer: C
Rationale: The correct answer is C: Fetal descent and position. In the second stage of labor, the priority assessment is to monitor fetal descent and position to ensure the baby is progressing through the birth canal correctly. This assessment helps determine if interventions are needed to prevent complications such as fetal distress or prolonged labor. Assessing the frequency of contractions (A) and cervical dilation (B) are important but not the priority in the second stage. Intensity of contractions (D) is also important but not as crucial as monitoring fetal descent and position.
What is the appropriate intervention for a mother with a third-degree perineal tear postpartum?
- A. Apply ice packs to the perineum
- B. Administer stool softeners as prescribed
- C. Encourage the mother to avoid heavy lifting
- D. Provide perineal exercises for faster recovery
Correct Answer: C
Rationale: The correct answer is C: Encourage the mother to avoid heavy lifting. After a third-degree perineal tear, it is crucial to prevent strain on the perineum to promote healing and prevent complications like infection or further tearing. Heavy lifting can increase pressure on the perineum, leading to delayed healing. Ice packs (A) may help reduce swelling initially but do not address the underlying issue. Stool softeners (B) can help prevent constipation and straining during bowel movements but do not directly impact perineal tear healing. Perineal exercises (D) are beneficial for strengthening the pelvic floor muscles in general but should be introduced gradually and not immediately postpartum with a severe tear.
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 assessing a client with a suspected diagnosis of abruptio placentae. Which finding is most indicative of this condition?
- A. Soft abdomen.
- B. Uterine tenderness and rigidity.
- C. Bright red, painless vaginal bleeding.
- D. Decreased fetal movements.
Correct Answer: B
Rationale: The correct answer is B: Uterine tenderness and rigidity. This finding is most indicative of abruptio placentae, which is the premature separation of the placenta from the uterine wall. Uterine tenderness and rigidity are classic signs due to the internal bleeding and blood accumulating between the placenta and uterine wall. This results in a tense and tender uterus.
A: Soft abdomen is incorrect as abruptio placentae typically presents with a firm, board-like abdomen due to uterine rigidity.
C: Bright red, painless vaginal bleeding is incorrect as abruptio placentae typically presents with dark red, painful vaginal bleeding.
D: Decreased fetal movements are incorrect as fetal distress can occur with abruptio placentae, but uterine tenderness and rigidity are more specific indicators of this condition.