Nokea
The nurse understands that many patients who experience violence become homeless to escape their situation. How can the nurse help these patients?
- A. Tell the patient to go back home in order to have a place to live.
- B. Tell the patient to get a job in order to have a place to stay.
- C. Refer the patient to a shelter.
- D. Refer the patient to the police.
Correct Answer: C
Rationale: The correct answer is C: Refer the patient to a shelter. This option is the most appropriate because it addresses the immediate need for a safe place to stay for patients experiencing violence and homelessness. Referring the patient to a shelter provides them with temporary housing, safety, and access to resources and support services. Options A and B are not suitable as they overlook the safety concerns of the patient and may put them at risk of further harm. Option D, referring the patient to the police, may not address the patient's need for shelter and support services. Therefore, option C is the most effective and compassionate way to help patients in this situation.
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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.
Which finding in a laboring mother requires immediate intervention?
- A. Contractions occurring every 5 minutes
- B. Late decelerations on fetal heart monitor
- C. Early decelerations on fetal heart monitor
- D. Elevated maternal temperature during labor
Correct Answer: D
Rationale: The correct answer is D: Elevated maternal temperature during labor. This finding indicates a potential infection, such as chorioamnionitis, which can be harmful to both the mother and the baby if not promptly treated. Immediate intervention is necessary to prevent complications like sepsis.
Contractions every 5 minutes (A) are within the normal range for active labor. Late decelerations (B) can indicate uteroplacental insufficiency and require monitoring but not immediate intervention unless persistent. Early decelerations (C) are usually benign and do not typically require immediate action.
A client at 34 weeks' gestation reports decreased fetal movements. What should the nurse advise first?
- A. Drink a glass of juice and lie down.
- B. Come to the clinic immediately.
- C. Monitor fetal movements for 24 hours.
- D. Call the healthcare provider tomorrow.
Correct Answer: A
Rationale: The correct answer is A: Drink a glass of juice and lie down. This advice is based on the concept that consuming juice can stimulate fetal movements due to the increase in blood sugar levels. Lying down also helps the client focus on feeling the movements. This initial step is non-invasive and can potentially address the decreased fetal movements promptly. Choices B and D delay action, which can be dangerous if there is a significant issue with the baby. Choice C might lead to unnecessary waiting and potential risks if the fetus is in distress.
The nurse is preparing a client for an amniocentesis. What is the priority nursing action before the procedure?
- A. Administer IV fluids.
- B. Obtain baseline vital signs.
- C. Ensure informed consent is signed.
- D. Position the client in the Trendelenburg position.
Correct Answer: C
Rationale: The correct answer is C: Ensure informed consent is signed. Before any invasive procedure like an amniocentesis, it is essential to ensure that the client has full understanding of the risks, benefits, and alternatives. This is crucial for autonomy and ethical practice. Administering IV fluids (choice A) is not a priority before an amniocentesis. Obtaining baseline vital signs (choice B) is important but not the priority over informed consent. Positioning the client in the Trendelenburg position (choice D) is not necessary for an amniocentesis procedure.
A nurse is teaching a client who is at 41 weeks of gestation about a non-stress test. Which of the following information should the nurse include in the teaching?
- A. "This test will confirm fetal lung maturity ".
- B. "This test will determine adequacy of placental perfusion".
- C. "This test will detect fetal infection".
- D. "This test will predict maternal readiness for labor".
Correct Answer: B
Rationale: The correct answer is B: "This test will determine adequacy of placental perfusion." The non-stress test is used to assess fetal well-being by monitoring fetal heart rate in response to fetal movement. It helps determine if the placenta is providing enough oxygen and nutrients to the fetus. This information is crucial in assessing the overall health and viability of the fetus.
A: "This test will confirm fetal lung maturity" - This statement is incorrect because the non-stress test does not assess fetal lung maturity. That is usually done through tests like amniocentesis.
C: "This test will detect fetal infection" - This statement is incorrect because the non-stress test does not detect fetal infection. Other tests like amniocentesis or blood tests are used for this purpose.
D: "This test will predict maternal readiness for labor" - This statement is incorrect as the non-stress test focuses on fetal well-being and does not predict maternal readiness for labor.