Nokea
A nurse is teaching about clomiphene citrate to a client who is experiencing infertility. Which of the following adverse effect should the nurse include?
- A. Tinnitus
- B. Urinary Frequency
- C. Breast Tenderness
- D. Chills
Correct Answer: C
Rationale: The correct answer is C: Breast Tenderness. Clomiphene citrate is a medication commonly used for infertility, and a common side effect is breast tenderness due to its estrogen-like effects on the body. Tinnitus (A), urinary frequency (B), and chills (D) are not typically associated with clomiphene citrate. Tinnitus could be related to ototoxic medications, urinary frequency could be due to diuretics, and chills could be due to infections or allergic reactions, but they are not commonly linked to clomiphene citrate. Therefore, the nurse should focus on educating the client about the potential adverse effect of breast tenderness when taking clomiphene citrate.
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A nurse caring for a client who is at 20 weeks of gestation and has trichomoniasis. Which of the following findings should the nurse expect?
- A. Thick, White Vaginal Discharge
- B. Urinary Frequency
- C. Vulva Lesions
- D. Malodorous Discharge
Correct Answer: D
Rationale: The correct answer is D: Malodorous Discharge. Trichomoniasis is a sexually transmitted infection caused by a parasite, typically presenting with a foul-smelling, greenish-yellow vaginal discharge. This discharge is a hallmark symptom of trichomoniasis due to inflammation and infection of the vaginal mucosa. Other choices are incorrect because: A) Thick, White Vaginal Discharge is more indicative of a yeast infection; B) Urinary Frequency is not a common symptom of trichomoniasis; C) Vulva Lesions are not typically associated with trichomoniasis at 20 weeks of gestation.
A nurse is assessing a client who is 27 weeks of gestation and has pre-eclampsia. Which of the following findings should the nurse report to the provider?
- A. Hemoglobin 14.8 g/dL
- B. Platelet count 60,000/mm³
- C. Creatinine 0.8 mg/dL
- D. Urine protein concentration 200 mg/24hr
Correct Answer: B
Rationale: The correct answer is B: Platelet count 60,000/mm³. In pre-eclampsia, there is a risk of developing HELLP syndrome, which includes hemolysis, elevated liver enzymes, and low platelet count. A platelet count of 60,000/mm³ indicates thrombocytopenia, a serious complication that can lead to bleeding and should be reported to the provider urgently. Choices A, C, and D are within normal limits for a pregnant client and are not indicative of an immediate concern in pre-eclampsia.
A nurse is caring for four clients. For which of the following clients should the nurse auscultate the fetal heart rate during the prenatal visit?
- A. A client who has an ultrasound that confirms a molar pregnancy
- B. A client who has a crown-rump length of 7 weeks gestation
- C. A client who has a positive urine pregnancy test 1 week after missed menses
- D. A client who has felt quickening for the first time
Correct Answer: D
Rationale: The correct answer is D. The nurse should auscultate the fetal heart rate for a client who has felt quickening for the first time during the prenatal visit. Quickening is the first fetal movements felt by the mother, typically occurring around 18-20 weeks gestation. Auscultating the fetal heart rate confirms the presence of fetal life and ensures the fetus is developing appropriately. This step is crucial in assessing fetal well-being and monitoring for any potential complications.
Choice A: A client with a molar pregnancy does not have a viable fetus; auscultating the fetal heart rate is not necessary.
Choice B: A client with a crown-rump length of 7 weeks gestation may be too early for fetal heart rate detection using auscultation.
Choice C: A positive urine pregnancy test alone does not indicate fetal viability; auscultation is needed to assess the fetus.
In summary, choice D is correct as it aligns with the timing of fetal movement and the need to assess
A nurse is caring for a client who is experiencing sore nipples from breastfeeding. Which of the following actions should the nurse take?
- A. Place a snug dressing on the client’s nipple when not breastfeeding
- B. Ensure the newborn’s mouth is wide open before latching to the breast
- C. Encourage the client to limit the newborn’s feeding to 10 min on each breast
- D. Instruct the client to begin the feeding with the nipple that is most tender
Correct Answer: B
Rationale: The correct answer is B: Ensure the newborn’s mouth is wide open before latching to the breast. This is the correct action to take to address sore nipples from breastfeeding. Ensuring a wide latch helps the baby to properly attach to the breast, reducing the pressure on the nipple and preventing further damage. A snug dressing (Option A) can worsen the condition by obstructing airflow and promoting moisture. Limiting feeding time (Option C) can lead to inadequate milk supply or poor weight gain. Starting with the most tender nipple (Option D) can prolong healing.
A nurse is assessing a client who is in preterm labor and has a new prescription for terbutaline 0.25 mg subcutaneous. For which of the following findings should the nurse withhold the medication and report to the provider?
- A. Fasting blood glucose 75 mg/dL
- B. Blood pressure 88/58 mmHg
- C. Urinary output 40 mL/hr
- D. FHR 120/min
Correct Answer: B
Rationale: Correct Answer: B (Blood pressure 88/58 mmHg)
Rationale: Terbutaline is a tocolytic medication used to inhibit preterm labor contractions by relaxing uterine smooth muscle. A low blood pressure of 88/58 mmHg indicates hypotension, a potential side effect of terbutaline. Hypotension can lead to decreased perfusion to the fetus and maternal organs, warranting withholding the medication and notifying the provider for further evaluation and management.
Summary of Incorrect Choices:
A: Fasting blood glucose 75 mg/dL - Normal blood glucose level, not a concerning finding related to terbutaline administration.
C: Urinary output 40 mL/hr - Normal urinary output, not a concerning finding related to terbutaline administration.
D: FHR 120/min - Normal fetal heart rate, not a concerning finding related to terbutaline administration.