Nokea
The nurse is monitoring a client in labor and suspects hypertonic uterine contractions. What is the priority nursing action?
- A. Provide pain relief measures.
- B. Prepare the client for an amniotomy.
- C. Promote ambulation every 30 minutes.
- D. Monitor the oxytocin infusion closely.
Correct Answer: A
Rationale: The correct answer is A: Provide pain relief measures. In hypertonic uterine contractions, the uterus contracts too frequently and intensely, leading to increased pain and potential fetal distress. Providing pain relief helps alleviate discomfort for the client and may reduce the risk of fetal distress. Other choices are incorrect because: B) Amniotomy may not be necessary and could potentially worsen the situation. C) Ambulation may not be safe or effective during hypertonic contractions. D) Monitoring the oxytocin infusion closely is important but not the priority in managing hypertonic contractions.
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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.
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 37 weeks' gestation reports swollen feet and hands. What assessment finding requires immediate intervention?
- A. Blood pressure of 150/95 mmHg.
- B. Weight gain of 1 pound in a week.
- C. Mild nausea after eating.
- D. Fetal movements are regular.
Correct Answer: A
Rationale: The correct answer is A: Blood pressure of 150/95 mmHg. This finding indicates gestational hypertension, which can progress to preeclampsia, a serious condition that requires immediate intervention to prevent complications for both the mother and baby. High blood pressure can lead to organ damage and placental insufficiency.
B: Weight gain of 1 pound in a week is within the normal range for late pregnancy and may not require immediate intervention.
C: Mild nausea after eating is a common pregnancy symptom and does not indicate an urgent issue.
D: Regular fetal movements are a positive sign of fetal well-being and do not require immediate intervention.
Which client teaching instruction is necessary for a pregnant client who is to undergo a glucose challenge test (GCT) as part of a routine pregnancy treatment plan at 28 weeks?
- A. No dietary restriction (done 24-28 weeks' gestation)
Correct Answer: A
Rationale: The correct answer is A: No dietary restriction (done 24-28 weeks' gestation). This is because the glucose challenge test (GCT) is typically performed between 24-28 weeks of gestation to screen for gestational diabetes. It is important not to have any dietary restrictions before the test to ensure accurate results. Restricting food intake before the test can lead to false results. Other choices are incorrect because they do not align with the standard practice of performing the GCT between 24-28 weeks and avoiding dietary restrictions before the test.
The nurse is educating a client about gestational diabetes. What is the most important teaching point?
- A. Avoid all carbohydrates.
- B. Check your blood sugar only when symptomatic.
- C. Monitor blood sugar regularly as prescribed.
- D. Increase your physical activity significantly.
Correct Answer: C
Rationale: The correct answer is C: Monitor blood sugar regularly as prescribed. This is crucial in managing gestational diabetes to ensure blood sugar levels are within target range, preventing complications for both mother and baby. Regular monitoring helps track the effectiveness of treatment and dietary adjustments. Avoiding all carbohydrates (A) is not recommended as some are necessary for energy. Checking blood sugar only when symptomatic (B) is insufficient as it may miss important fluctuations. Increasing physical activity significantly (D) is beneficial but not the most important teaching point compared to consistent blood sugar monitoring.