Nokea
The nurse is teaching a client about signs of preterm labor. Which symptom should be reported immediately?
- A. Increased fetal movements.
- B. Lower back pain and cramping.
- C. Mild swelling of the feet.
- D. Occasional Braxton Hicks contractions.
Correct Answer: B
Rationale: Lower back pain and cramping may indicate preterm labor and should be reported promptly.
You may also like to solve these questions
The nurse is monitoring a client in the second stage of labor. What finding indicates the client is ready to push?
- A. Membranes have ruptured.
- B. Cervix is completely dilated.
- C. Client reports back pain.
- D. Contractions are 10 minutes apart.
Correct Answer: B
Rationale: Complete cervical dilation marks the beginning of the second stage, signaling readiness to push.
A nurse is caring for a client who is 1 day postpartum and is taking a sitz bath. To determine the client's tolerance of the procedure, which of the following assessments should the nurse perform?
- A. Bladder distention
- B. Pulse rate
- C. Respiratory rate
- D. Color of lochia
Correct Answer: B
Rationale: The nurse should assess the client's pulse rate to determine the client's tolerance of the sitz bath. An elevated pulse may indicate that the sitz bath is causing discomfort or stress to the client. Monitoring the pulse rate is essential to ensure the client's safety and comfort during the procedure. Bladder distention, respiratory rate, and color of lochia are important assessments in postpartum care but are not specifically related to determining the client's tolerance of a sitz bath.
The nurse is providing education on a medical abortion. How would she describe the action of the medications?
- A. Medications thicken the lining of the uterus and decrease uterine contractions.
- B. Medications stop the fetal heart and induce contractions.
- C. Medications soften the cervix, cause uterine lining necrosis, and induce contractions.
- D. Medications thicken the cervix and the uterine lining.
Correct Answer: C
Rationale: Medications used in a medical abortion typically consist of a combination of Mifepristone and Misoprostol. The action of these medications involves three main effects: softening the cervix to facilitate the expulsion of the pregnancy tissue, causing necrosis of the uterine lining to disrupt the pregnancy, and inducing contractions to expel the contents of the uterus. This process is different from a surgical abortion, which involves a procedure to remove the pregnancy tissue from the uterus.
A client is receiving positive-pressure mechanical ventilation. Which of the following interventions should the nurse implement to prevent complications? (Select one that doesn't apply.)
- A. Elevate the head of the bed to at least 30°.
- B. Apply restraints if the client becomes agitated.
- C. Administer pantoprazole as prescribed.
- D. Reposition the endotracheal tube to the opposite side of the mouth daily.
Correct Answer: D
Rationale: Repositioning the endotracheal tube to the opposite side of the mouth daily is not a standard practice in preventing complications in a client receiving positive-pressure mechanical ventilation. This action may disrupt the secure placement of the endotracheal tube and increase the risk of complications. Elevating the head of the bed to at least 30° helps prevent aspiration and ventilator-associated pneumonia. Applying restraints if the client becomes agitated helps maintain the safety of the client by preventing self-extubation or accidental dislodgement of tubes. Administering pantoprazole as prescribed helps prevent stress ulcers, a common complication in critically ill patients on mechanical ventilation.
The nurse is attempting to explain physiologic birth. What do they say?
- A. Physiologic birth involves interventions that do not harm the baby.â€
- B. Physiologic birth occurs only in birth centers.â€
- C. If your partner and I give you support, you can have a birth without medical intervention.â€
- D. If you want to have a cesarean birth, we can ask your health-care provider to schedule it.â€
Correct Answer: C
Rationale: Physiologic birth focuses on minimal intervention, supported by a calm environment and supportive care.