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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.
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A patient is seen in the primary care clinic for a sinus infection and is prescribed antibiotics. The only other medication that this patient currently takes is an oral contraceptive. What is the most important education the nurse must give to the patient regarding her medications?
- A. If you have nausea with this combination of medication, make sure to take them with food.
- B. You must use a backup method for contraception while taking antibiotics.
- C. Oral contraceptives are contraindicated with many antibiotics.
- D. No education is necessary; these medications do not interact.
Correct Answer: B
Rationale: Step 1: Antibiotics can reduce the effectiveness of oral contraceptives by altering gut flora.
Step 2: Failure to use a backup method can lead to unintended pregnancy.
Step 3: Therefore, it is crucial for the nurse to educate the patient on using a backup method to prevent pregnancy.
Summary: Choice A is incorrect as nausea is not the main concern. Choice C is incorrect as not all antibiotics interact with oral contraceptives. Choice D is incorrect as there is a potential interaction between antibiotics and oral contraceptives.
16wks gestation reports for a triple screen test. What statements determines understanding?
- A. "This test can be used as a screening for spina bifida."
- B. "This test is a screen test, and I will need other testing if I have abn results."
- C. "this test can indicate if I may be at an increased risk for having a child with down syndrome."
- D. A triple screen test is a screening tool. Maternal blood is drawn and alpha-fetoprotein, hcg, and estriol values are assessed to determine if the mother is at an increased risk for neural tube defects or chromosomal trisomy's. Spina bifida and downs syndrome are the two most common risks.
Correct Answer: D
Rationale: Step-by-step rationale for why answer D is correct:
1. A triple screen test includes assessing alpha-fetoprotein, hCG, and estriol levels.
2. These values help determine the risk for neural tube defects and chromosomal trisomies.
3. The test does not directly diagnose spina bifida but assesses neural tube defects.
4. Down syndrome risk is also evaluated, not diagnosed directly.
5. Answer D provides a comprehensive explanation of the test components and its purpose, aligning with the test's actual function.
Summary of why other choices are incorrect:
A. Incorrect because the test screens for neural tube defects and chromosomal trisomies, not just spina bifida.
B. Incorrect because the test is a screening tool for specific conditions, not a definitive diagnostic test.
C. Incorrect because the test assesses multiple conditions, not just Down syndrome specifically.
The nurse is assessing a client with suspected placenta previa. Which finding supports this diagnosis?
- A. Painful, bright red bleeding.
- B. Painless, bright red bleeding.
- C. Hard, rigid abdomen.
- D. Decreased fetal movements.
Correct Answer: B
Rationale: The correct answer is B: Painless, bright red bleeding. Placenta previa is characterized by painless vaginal bleeding due to the placenta covering the cervical os. Bright red blood indicates fresh bleeding from the lower uterus. This finding supports the diagnosis as it aligns with the classic presentation of placenta previa.
A: Painful, bright red bleeding is not characteristic of placenta previa, as the bleeding is usually painless.
C: A hard, rigid abdomen is more indicative of a uterine rupture or abruption, not placenta previa.
D: Decreased fetal movements are not directly associated with placenta previa; this finding may suggest fetal distress but is not specific to this condition.
The nurse is performing a nonstress test. What result indicates a reactive test?
- A. No fetal movements noted.
- B. Two accelerations in 20 minutes.
- C. Baseline fetal heart rate of 170 beats/minute.
- D. Variable decelerations.
Correct Answer: B
Rationale: The correct answer is B because two accelerations in 20 minutes are indicative of a reactive nonstress test. This pattern suggests that the fetal heart rate is reacting appropriately to fetal movement, indicating good oxygenation and neurologic integrity. Choice A is incorrect as fetal movements are essential for the test. Choice C is incorrect as a baseline heart rate of 170 bpm is considered high. Choice D is incorrect as variable decelerations are concerning for fetal distress.
What is the nurse's first action for a newborn showing signs of hypoglycemia?
- A. Feed the newborn formula immediately
- B. Encourage breastfeeding or formula feeding
- C. Monitor glucose levels every hour
- D. Notify the healthcare provider immediately
Correct Answer: A
Rationale: The correct answer is A: Feed the newborn formula immediately. The first action for a newborn showing signs of hypoglycemia is to provide them with a source of glucose to raise their blood sugar levels quickly. Formula feeding is an effective way to achieve this as it provides a concentrated source of glucose. Encouraging breastfeeding or formula feeding (choice B) is a good option but may not address the immediate need for glucose. Monitoring glucose levels every hour (choice C) is important but not the first action to take in an acute situation. Notifying the healthcare provider immediately (choice D) is necessary but should come after addressing the immediate need for glucose.