Nokea
A woman is 16 weeks pregnant and she had cramping backache and mild bleeding for the past 3 days. The HCP determines she is dilated 2cm, 10% effaced, membranes intact. She's crying and saying to the nurse is my baby going to be okay? In addition to acknowledging the patient's fear the nurse should also say:
- A. Your cervix has begun to dilate, this is a serious sign, we will continue to monitor you and the baby for now
- B. I really can't say but when your physicians arrive, I'll ask her talk to you about it
- C. You baby will be fine, we will start an IV and get this stopped in no time at all
- D. You are going to miscarry, but you should be relieved because most miscarriages are the result of abnormalities in the fetus
Correct Answer: A
Rationale: Step 1: Acknowledge the patient's fear and anxiety.
Step 2: Provide a clear and honest response regarding the situation.
Step 3: Explain the significance of cervical dilation at 16 weeks.
Step 4: Assure the patient that they will be closely monitored.
Step 5: Offer support and comfort to the patient.
Summary:
Choice A is correct because it addresses the patient's concerns, acknowledges the seriousness of the situation, provides information about cervical dilation, and reassures the patient about monitoring. Choices B, C, and D are incorrect because they do not provide accurate information or address the situation appropriately, which could further distress the patient.
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The nurse is performing a prenatal assessment. What finding is considered a positive sign of pregnancy?
- A. Positive pregnancy test.
- B. Auscultation of fetal heart tones.
- C. Hegar's sign.
- D. Chadwick's sign.
Correct Answer: B
Rationale: The correct answer is B, auscultation of fetal heart tones, because it is a definitive sign of pregnancy indicating the presence of a fetus. This can be heard around 10-12 weeks of gestation using a Doppler device. It is a positive sign as it directly confirms the existence of a developing fetus.
A: A positive pregnancy test is a probable sign and can indicate pregnancy but is not definitive.
C: Hegar's sign is a probable sign characterized by softening of the lower uterine segment, not specific to pregnancy.
D: Chadwick's sign is a probable sign of pregnancy indicated by bluish discoloration of the cervix, vagina, and labia, not a definitive sign of pregnancy.
The nurse is teaching a client about morning sickness. What recommendation should the nurse provide?
- A. Eat large meals three times a day.
- B. Drink fluids with meals.
- C. Consume dry crackers before getting out of bed.
- D. Avoid eating before bedtime.
Correct Answer: C
Rationale: The correct answer is C: Consume dry crackers before getting out of bed. This recommendation helps alleviate morning sickness by providing a bland and easily digestible snack to settle the stomach before getting up. By consuming dry crackers, the client can avoid an empty stomach, which can contribute to nausea. Eating large meals three times a day (A) can worsen morning sickness due to heavy digestion, while drinking fluids with meals (B) may exacerbate nausea. Avoiding eating before bedtime (D) is generally recommended, but it does not specifically address morning sickness.
A nurse is caring for a client who experienced a cesarean birth due to dysfunctional labor. The client states that she is disappointed that she did not have natural childbirth. Which of the following responses should the nurse make?
- A. "It sounds like you are feeling sad that things didn't go as planned."
- B. "At least you know you have a healthy baby."
- C. "Maybe next time you can have a vaginal delivery."
- D. "You can resume sexual relations sooner than if you had delivered vaginally."
Correct Answer: A
Rationale: Step 1: Empathy - The nurse acknowledges the client's feelings of disappointment, showing empathy and understanding.
Step 2: Validation - By stating "It sounds like you are feeling sad that things didn't go as planned," the nurse validates the client's emotions, making her feel heard and supported.
Step 3: Therapeutic Communication - This response encourages the client to express her feelings further, promoting open communication and trust in the nurse-client relationship.
Summary:
Choice B is incorrect as it dismisses the client's emotional concerns and focuses solely on the baby's health. Choice C is incorrect as it minimizes the client's current experience and may increase feelings of inadequacy. Choice D is incorrect as it is not relevant to the client's emotional needs and may be perceived as insensitive.
What is a statement that best describes reproductive health?
- A. Reproductive health focuses solely on the ability to reproduce and have children.
- B. Reproductive health encompasses physical well-being but does not include mental and social aspects.
- C. Reproductive health involves complete physical, mental, and social well-being related to the reproductive system.
- D. Reproductive health is limited to making informed decisions about contraception methods.
Correct Answer: C
Rationale: The correct answer is C because reproductive health is not just about the ability to reproduce but also includes mental and social well-being. This choice aligns with the World Health Organization's definition of reproductive health, which emphasizes holistic well-being. Choice A is incorrect as it oversimplifies reproductive health. Choice B is incorrect because reproductive health should address all aspects of well-being. Choice D is incorrect as reproductive health goes beyond just contraception to encompass a broader scope of health and well-being.
The nurse is assessing a client in labor and notes persistent late decelerations on the monitor. What is the priority action?
- A. Reposition the client to her left side.
- B. Administer oxygen via face mask.
- C. Increase IV fluids.
- D. Notify the healthcare provider.
Correct Answer: A
Rationale: The correct answer is A: Reposition the client to her left side. This is the priority action because late decelerations indicate uteroplacental insufficiency, possibly due to compression of the umbilical cord. Repositioning the client to her left side can help improve blood flow to the placenta by reducing pressure on the vena cava, thus optimizing fetal oxygenation. Administering oxygen (B) is important but not the immediate priority. Increasing IV fluids (C) may not directly address the cause of late decelerations. Notifying the healthcare provider (D) is important but should come after immediate interventions.