Nokea
The nurse is monitoring a client in active labor. What finding indicates the need for immediate intervention?
- A. Contractions every 2–3 minutes.
- B. Fetal heart rate of 90 beats/minute.
- C. Cervical dilation of 6 cm.
- D. Client reports back pain.
Correct Answer: B
Rationale: A fetal heart rate of 90 beats/minute is bradycardia, indicating potential fetal distress.
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How should a nurse assess for proper latch during breastfeeding?
- A. Ensure the baby's nose is covered during feeding
- B. Ensure the baby's lips are sealed around the areola
- C. Check for audible swallowing during feeding
- D. Encourage frequent feeding attempts
Correct Answer: B
Rationale: Ensuring the baby's lips are sealed around the areola promotes effective milk transfer and reduces pain.
A client in the first trimester reports nausea. What dietary recommendation should the nurse make?
- A. Eat dry crackers before getting out of bed.
- B. Avoid eating throughout the day.
- C. Increase intake of spicy foods.
- D. Consume large, infrequent meals.
Correct Answer: A
Rationale: Dry crackers before rising can help manage nausea by stabilizing blood sugar and reducing gastric discomfort.
The nurse is seeing a 17-year-old female in the clinic for complaints of acne. The nurse plans on taking advantage of this teachable moment with the teen. Which topics will the nurse include in the teen's teaching plan?
- A. Smoking habits, folic acid intake, and heart disease
- B. Hyperlipidemia, distracted driving, and menstrual history
- C. Sexual activity, contraception, and screening for violence
- D. Optimum weight, hypothyroidism, and sexually transmitted diseases
Correct Answer: D
Rationale: The most appropriate topics for the nurse to include in the teaching plan for the 17-year-old female with acne are optimum weight, hypothyroidism, and sexually transmitted diseases. Acne can be influenced by hormonal changes, which can be impacted by weight, thyroid function, and hormonal fluctuations related to sexual health. Educating the teen about these topics can help her understand potential contributing factors to her acne and empower her to make informed decisions about her health and lifestyle. It is important to address issues that are relevant to the teen's current health concerns while also providing valuable information for her overall well-being.
The nurse is planning to admit a pregnant client who is obese. Which potential client needs should the nurse anticipate?
- A. Routine administration of subcutaneous heparin may be prescribed.
- B. Bed rest as a necessary preventive measure may be prescribed.
- C. An overbed lift may be necessary if the client requires a cesarean section.
- D. Thromboembolism stockings or sequential compression devices may be prescribed.
Correct Answer: D
Rationale: Obese clients may need thromboembolism prevention and specialized equipment for safe cesarean handling.
Narcotic analgesia is administered to a laboring patient at 10am. The infant is delivered at 12:30pm. The nurse would anticipate what?
- A. Neonatal respiratory depression
- B. Increased infant alertness
- C. Decreased fetal heart rate variability
- D. No effects on the neonate
Correct Answer: A
Rationale: Narcotic analgesia, when administered to a laboring patient, can cross the placenta and affect the infant. It can cause neonatal respiratory depression in the newborn after delivery. This is because the medication can depress the respiratory drive of the infant, leading to potentially serious breathing problems. It is important for the healthcare provider to closely monitor and assess the newborn for signs of respiratory distress in such cases.