Nokea
The nurse provides education to the person undergoing a surgical abortion. What response by the person shows an understanding of the education?
- A. “It’s good I won’t have any pain after the procedure.â€
- B. “I think I’m sure about my decision.â€
- C. “I should call if I soak a pad in 2 hours.â€
- D. “I should follow up for contraception counseling at my annual exam in 6 months.â€
Correct Answer: C
Rationale: The correct answer is C because soaking a pad in 2 hours could indicate excessive bleeding, a potential complication after a surgical abortion. This response shows understanding of the education provided by the nurse about when to seek immediate medical attention.
Choice A is incorrect because it is not true that there will be no pain after a surgical abortion; pain is a common experience post-procedure. Choice B is incorrect because it does not demonstrate an understanding of the key information provided during education. Choice D is incorrect because contraception counseling should be addressed sooner than 6 months post-abortion to prevent unintended pregnancies.
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The nurse is assessing a client with suspected chorioamnionitis. What is the priority nursing assessment?
- A. Assess for foul-smelling vaginal discharge.
- B. Monitor maternal blood pressure.
- C. Evaluate fetal heart rate.
- D. Check maternal glucose levels.
Correct Answer: C
Rationale: The correct answer is C: Evaluate fetal heart rate. In chorioamnionitis, fetal distress can occur due to infection and inflammation of the fetal membranes. Monitoring fetal heart rate is crucial to assess the well-being of the baby. Assessing for foul-smelling discharge (A) is important but not the priority. Monitoring maternal blood pressure (B) and checking glucose levels (D) are relevant assessments but do not address the immediate risk of fetal distress in chorioamnionitis.
A 28-year-old patient has decided to use the patch contraception. The nurse is educating her on the best site to use. Where is the best place to put the patch? Select all that apply.
- A. Buttocks
- B. Neck
- C. Leg
- D. Arm
Correct Answer: B
Rationale: The correct answer is B: Neck. The patch contraception is most effective when applied to a clean, dry, and hairless area of the body. The neck is a suitable site because it is easily accessible, non-occlusive, and less likely to be affected by clothing friction. Placing the patch on the neck also helps avoid skin irritation and allows for optimal absorption of hormones.
Choice A: Buttocks - The buttocks may not be an ideal site as it can be covered by clothing and may not allow for proper adherence and absorption.
Choice C: Leg - The leg is not typically recommended as a site for the patch due to movement and friction from clothing that may affect patch adhesion and hormone absorption.
Choice D: Arm - While the arm is a possible site for the patch, it is not as ideal as the neck because it may be subject to more movement and rubbing against clothing, potentially affecting patch adherence and effectiveness.
The nurse is caring for a client in the third trimester reporting severe right upper quadrant pain and nausea. What condition should the nurse suspect?
- A. Placenta previa.
- B. HELLP syndrome.
- C. Hyperemesis gravidarum.
- D. Abruptio placentae.
Correct Answer: B
Rationale: The correct answer is B: HELLP syndrome. In the third trimester, severe right upper quadrant pain and nausea can indicate HELLP syndrome, a serious pregnancy complication involving hemolysis, elevated liver enzymes, and low platelet count. The pain and nausea are due to liver and gallbladder involvement. Placenta previa typically presents with painless vaginal bleeding, not upper quadrant pain. Hyperemesis gravidarum causes severe nausea and vomiting but not specific upper quadrant pain. Abruptio placentae presents with sudden-onset abdominal pain and vaginal bleeding.
A nurse is reviewing signs of effective breathing with a client who is 5 days postpartum. Which of the following information should the nurse include in the teaching?
- A. "You should feel a tugging sensation when the baby is sucking.
- B. You should expect your baby to have two to three wet diapers in 24hour period
- C. "Your baby's urine should appear dark and concentrated".
- D. "Your breast should stay firm after the baby breastfeeds".
Correct Answer: B
Rationale: Rationale: Choice B is correct because a newborn should have at least 6-8 wet diapers in a 24-hour period, indicating adequate hydration and effective breastfeeding. This frequency of wet diapers is a sign of adequate milk intake and hydration for the baby, which is crucial for their growth and development. Choices A, C, and D are incorrect because feeling a tugging sensation, dark and concentrated urine, and firm breasts are not indicators of effective breathing or breastfeeding in a newborn.
The nurse is assessing a client in the active stage of labor. Which findings indicate to the nurse that the client is beginning the second stage of labor?
- A. The membranes have ruptured.
- B. The cervix is dilated completely.
- C. The client begins to expel clear vaginal fluid.
- D. The spontaneous urge to push is initiated from perineal pressure.
Correct Answer: B
Rationale: The correct answer is B because complete dilation of the cervix marks the transition from the first to the second stage of labor. This indicates that the client is ready to start pushing the baby out. Choice A is incorrect as ruptured membranes can occur in any stage of labor. Choice C is incorrect as clear vaginal fluid expulsion is not a specific indicator of the second stage. Choice D is incorrect as the urge to push can be experienced in the first stage as well.