The nurse is educating a client about kick counts. When should the client contact the healthcare provider?
- A. Fewer than 10 movements in 2 hours.
- B. Fewer than 5 movements in 1 hour.
- C. No movements after drinking juice.
- D. No movements for 12 hours.
Correct Answer: A
Rationale: Fewer than 10 movements in 2 hours is concerning and warrants further evaluation.
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Which nursing action is most appropriate for a newborn experiencing apnea?
- A. Place the newborn in a prone position
- B. Administer oxygen and stimulate the newborn
- C. Place the newborn under a radiant warmer
- D. Initiate chest compressions immediately
Correct Answer: B
Rationale: Administering oxygen and stimulating the newborn resolves apnea episodes.
The nurse is assessing a client at 20 weeks' gestation with suspected anemia. What lab finding supports this diagnosis?
- A. Hemoglobin of 10 g/dL.
- B. Platelet count of 150,000 mm3.
- C. Hematocrit of 40%.
- D. White blood cell count of 8,000 mm3.
Correct Answer: A
Rationale: A hemoglobin level of 10 g/dL is below normal during pregnancy and indicates anemia.
The nurse assesses a patient for medical eligibility for contraceptive use. What is the meaning of an MEC score of 1?
- A. There is no restriction for the use of the contraceptive method.
- B. There is an unacceptable health risk if the contraceptive method is used.
- C. There is a risk that outweighs the advantages of the contraceptive method.
- D. There is an advantage of using a contraceptive method that outweighs any risk.
Correct Answer: A
Rationale: In the context of medical eligibility for contraceptive use, an MEC (Medical Eligibility Criteria) score of 1 indicates that there are no restrictions for using the particular contraceptive method. A score of 1 suggests that the advantages of using the contraceptive method outweigh any potential risks, making it a safe and recommended choice for the patient. Therefore, a patient with an MEC score of 1 can use the contraceptive method without any concerns regarding health risks or restrictions.
Mother in late middle age who is certain she is not pregnant tells
the nurse during an office visit she has urinary problems as well as
sensation of bearing down and of something in the vagina. The nurse
should realize that the client is most likely suffering from:
- A. Uterine prolapse
- B. Cystocele/rectocele
- C. Urinary tract infection (UTI)
- D. Endometriosis
Correct Answer: B
Rationale: A cystocele/rectocele occurs when the supportive tissue between a woman's bladder and vaginal wall weakens, allowing the bladder to bulge into the vagina. This can lead to urinary problems such as difficulty emptying the bladder completely, frequent urination, and urinary incontinence. The fact that the mother is in late middle age and certain she is not pregnant, combined with her urinary problems, suggests that she may be experiencing symptoms of a cystocele/rectocele. It is important for the nurse to further assess the client's symptoms and provide appropriate education and treatment options.
The nurse is preparing a postpartum client for discharge. What statement indicates the need for further teaching?
- A. I will avoid heavy lifting for at least 6 weeks.
- B. I can resume sexual activity when I stop bleeding.
- C. I should call my doctor if I experience a fever or foul-smelling discharge.
- D. I will schedule my postpartum visit in 6 weeks.
Correct Answer: B
Rationale: Sexual activity should be resumed based on the healthcare provider's recommendation, not just the cessation of bleeding.