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The nurse is providing discharge instructions to a 28-year-old client who received methotrexate for an ectopic pregnancy. Which should the discharge instructions include?
- A. Make sure to take folic acid
- B. Make an appointment to see her provider in 6 weeks
- C. Flush the toilet twice after she urinates for the next 24 hours
- D. Resume all activity in 48 hours
Correct Answer: C
Rationale: The correct answer is C. Methotrexate is a chemotherapy agent that can be harmful to others if not properly eliminated from the body. Instructing the client to flush the toilet twice after urination for the next 24 hours helps to reduce the risk of exposing others to the medication through urine. This precaution is important to prevent potential harm to others.
Choices A, B, and D are incorrect:
A: Taking folic acid is generally recommended to reduce side effects of methotrexate but is not directly related to the safety of others.
B: While follow-up appointments are important, the immediate safety concern of methotrexate elimination is more critical.
D: Resuming all activity in 48 hours may not be appropriate depending on the individual's response to methotrexate and their recovery process.
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The nurse is caring for a client who is at 24 weeks gestation. Which assessment requires further intervention?
- A. Hemoglobin 11 and hematocrit 33
- B. Blood pressure of 130/80
- C. Patient has slight pedal swelling
- D. Urine dipstick for protein 3+
Correct Answer: D
Rationale: The correct answer is D because a urine dipstick showing protein of 3+ indicates significant proteinuria, a sign of preeclampsia in pregnancy. Preeclampsia can lead to serious complications for both the mother and the baby, such as eclampsia and fetal growth restriction. The nurse should further assess the client's blood pressure, perform additional tests for preeclampsia, and closely monitor the client's condition.
Choice A: Hemoglobin and hematocrit levels are within normal range for pregnancy and do not require immediate intervention.
Choice B: Blood pressure of 130/80 is slightly elevated but not concerning at this gestational age. Close monitoring is recommended.
Choice C: Slight pedal swelling is common in pregnancy due to fluid retention and usually does not indicate a serious issue.
The nurse is caring for a woman with a history of a previous preterm birth. Based on current knowledge related to cervical incompetency, which should the nurse do?
- A. Prepare the woman for an abdominal ultrasound
- B. Place the patient on her left side to increase perfusion to the fetus
- C. Be prepared to discuss the action and side effects of progesterone
- D. Monitor the patient’s blood pressure closely
Correct Answer: C
Rationale: The correct answer is C because progesterone is a recommended treatment for cervical incompetency to prevent preterm birth. Progesterone helps support the uterine lining and decrease the risk of preterm labor. Therefore, discussing the action and side effects of progesterone with the patient is essential.
A: While an abdominal ultrasound may provide information about the cervix, it is not the immediate priority in this case.
B: Placing the patient on her left side is a common practice for improving blood flow, but it is not directly related to managing cervical incompetency.
D: Monitoring blood pressure is important in prenatal care, but it is not specifically related to the management of cervical incompetency in this context.
The nurse is monitoring a woman with signs and symptoms of preterm labor. Which does the nurse include in the teaching plan?
- A. Importance of performing daily fetal movement counts
- B. Need to refrain from putting any objects in the vagina
- C. Need to take a daily stool softener
- D. The need to decrease fluid intake
Correct Answer: B
Rationale: The correct answer is B: Need to refrain from putting any objects in the vagina. This is important to prevent irritating the cervix and potentially triggering preterm labor. Putting objects in the vagina can introduce bacteria, leading to infection, which can increase the risk of preterm labor. Option A is important for monitoring fetal well-being but not directly related to preventing preterm labor. Option C is not relevant to preterm labor. Option D is incorrect as hydration is important in preventing preterm labor.
The nurse is caring for a patient who is receiving magnesium sulfate for pre-eclampsia. Which assessments will be of the highest priority?
- A. Assessing lung sounds
- B. Assessing blood sugar level
- C. Encouraging fluid intake
- D. Assessing for pitting edema
Correct Answer: A
Rationale: The correct answer is A because magnesium sulfate can cause respiratory depression, necessitating close monitoring of lung sounds to detect any signs of respiratory distress. Assessing lung sounds is crucial for early detection and intervention. Blood sugar level (B) monitoring is not directly related to magnesium sulfate therapy. Encouraging fluid intake (C) may be important, but not as critical as assessing lung sounds. Assessing for pitting edema (D) is important for overall assessment but not the highest priority in this scenario.
The doctor suspects that the client is in preterm labor. Which symptom is consistent with this diagnosis?
- A. Severe pain in the lower quadrant
- B. Severe pain and hard abdomen to palpation
- C. Painless vaginal bleeding
- D. Abdominal cramping and lower back pain
Correct Answer: D
Rationale: The correct answer is D: Abdominal cramping and lower back pain. This symptom is consistent with preterm labor as it indicates contractions and possible cervical changes. Severe pain in the lower quadrant (A) is more likely related to other conditions like ectopic pregnancy. Severe pain and hard abdomen to palpation (B) may suggest a more acute issue like placental abruption. Painless vaginal bleeding (C) is typically seen in conditions like placenta previa. Therefore, choice D is the most indicative of preterm labor based on the symptoms presented.