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The nurse is teaching a client about preterm labor prevention. What instruction is most appropriate?
- A. Drink at least 8–10 glasses of water daily.
- B. Avoid lying down during the day.
- C. Increase physical activity levels.
- D. Reduce protein intake.
Correct Answer: A
Rationale: The correct answer is A because adequate hydration helps prevent preterm labor by maintaining amniotic fluid levels and preventing dehydration-induced contractions. Drinking 8-10 glasses of water daily ensures proper hydration.
B is incorrect because lying down during the day does not have a direct impact on preterm labor prevention.
C is incorrect as excessive physical activity can sometimes trigger preterm labor instead of preventing it.
D is incorrect as protein intake is important for fetal development and reducing it can lead to nutritional deficiencies, but it is not a direct factor in preventing preterm labor.
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In addition to the bolus of fluid which medication should she be given to increase blood pressure?
- A. Ephedrine
- B. Terbutaline
- C. Epinephrine
- D. Epifoam
Correct Answer: A
Rationale: The correct answer is A: Ephedrine. Ephedrine is a sympathomimetic amine that acts on alpha and beta adrenergic receptors to increase blood pressure. It is commonly used to treat hypotension. Terbutaline (B) and Epinephrine (C) are bronchodilators that can lower blood pressure. Epifoam (D) is a topical medication for skin conditions and does not affect blood pressure. Therefore, Ephedrine is the most appropriate choice to increase blood pressure in this scenario.
A nurse is a prenatal clinic is completing a skin assessment for a pregnant client in the second trimester. Which clinical findings should the nurse expect (select all that apply)?
- A. Eczema
- B. Psoriasis C.Linea nigra
- C. Chloasma
- D. Striae gravidarum C, D, E
Correct Answer: C
Rationale: The correct answer is C: Linea nigra. During the second trimester of pregnancy, hormonal changes can lead to the development of Linea nigra, a dark vertical line that appears on the abdomen. This is a common skin change in pregnant women.
Explanation:
1. Eczema (choice A) and Psoriasis (choice B) are chronic skin conditions that are not typically associated with pregnancy. These conditions are not expected findings during the second trimester.
2. Chloasma (choice C) is also known as the "mask of pregnancy" and presents as dark patches on the face. This is a common skin change during pregnancy, especially in the second trimester.
3. Striae gravidarum (choice D) are stretch marks that may develop on the abdomen, breasts, and thighs during pregnancy. While this is a common skin change in pregnancy, it is not one of the expected findings in the second trimester according to the question.
In summary, the correct
The nurse should designate the highest priority health outcomes to be:
- A. Oxygenation will remain adequate
- B. Body temperature will remain stable
- C. Weight will increase by 30g per day
- D. Heart rate will recover to an acceptable range
Correct Answer: A
Rationale: The correct answer is A because adequate oxygenation is a critical health outcome necessary for cellular function and overall well-being. Without sufficient oxygenation, other bodily functions can be compromised. Stable body temperature (B) is important but not as immediately life-threatening as inadequate oxygenation. Weight gain (C) is not a priority health outcome in this scenario. Heart rate recovery (D) is important but ensuring adequate oxygenation takes precedence in this case.
The nurse is monitoring a client in labor with an epidural. What finding requires immediate intervention?
- A. Blood pressure of 100/60 mmHg.
- B. Fetal heart rate of 90 beats/minute.
- C. Client reports warmth in the lower extremities.
- D. Contractions every 5 minutes.
Correct Answer: B
Rationale: The correct answer is B: Fetal heart rate of 90 beats/minute. A fetal heart rate of 90 bpm indicates fetal distress and requires immediate intervention to prevent potential complications. Decreased fetal heart rate can be a sign of fetal hypoxia or distress. The other choices are not as concerning in this context. A blood pressure of 100/60 mmHg is within normal range. The client reporting warmth in the lower extremities is a common side effect of epidural anesthesia. Contractions every 5 minutes may indicate progress in labor but do not require immediate intervention unless associated with fetal distress.
A nurse is providing teaching about terbutaline to a client who is experiencing preterm labor. Which of the following statement by client indicates an understanding of the teaching?
- A. "The medication could cause me to experience heart palpitation"
- B. "This medication could cause me to experience blurred vision"
- C. "This medication could cause me to experience ringing in my ears"
- D. "This medication could cause me to experience frequent "¦"
Correct Answer: A
Rationale: The correct answer is A. The statement "The medication could cause me to experience heart palpitations" indicates understanding because terbutaline, a beta-agonist used to stop preterm labor, can indeed cause heart palpitations as a common side effect due to its impact on the cardiovascular system. This shows the client has grasped a potential side effect of the medication.
The other choices are incorrect:
B: "This medication could cause me to experience blurred vision" - Blurred vision is not a common side effect of terbutaline.
C: "This medication could cause me to experience ringing in my ears" - Ringing in the ears is not a common side effect of terbutaline.
D: "This medication could cause me to experience frequent " - Incomplete statement, not indicating understanding of a specific side effect.