Nokea
The triage nurse is interviewing a client, 19 years old, unmarried, who states, 'I felt a hard thing on the lip of my vagina this morning. It doesn’t hurt.' Which of the following questions is most important for the nurse to ask at this time?
- A. Have any of your partners ever hurt you?'
- B. Do you ever have unprotected intercourse?'
- C. Have you ever had a baby?'
- D. Do you think you may be pregnant?'
Correct Answer: B
Rationale: Unprotected intercourse increases the risk of sexually transmitted infections (STIs), which could explain the hard lump.
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On the third postpartum day a client tells the nurse that she feels sad and that she cries easily. The nurse should explain about which of the following?
- A. These feelings are normal and should diminish when the baby is a week or so old.
- B. The physician will likely order an antidepressant for the client to take at home.
- C. If the client focuses on the fact that she has a healthy baby, the feelings will cease.
- D. When the client is home with her family and friends, her sad feelings will disappear.
Correct Answer: A
Rationale: Postpartum blues are common and usually resolve within a week or two. Persistent sadness may indicate postpartum depression, but initial feelings are normal.
When should the nurse begin discharge planning?
- A. When the patient is ready
- B. Close to the time of discharge
- C. Upon admission to the hospital
- D. After an order is written/prescribed
Correct Answer: C
Rationale: Discharge planning begins the moment a patient is admitted to a health care facility.
The nurse is caring for a client being monitored for oligohydramnios. The NST is nonreactive. Which findings correlate with these results?
- A. Less than 2 accelerations in 20 to 40 minutes
- B. Accelerations of at least 15 bpm lasting at least 15 seconds (more than 32 weeks gestation)
- C. Accelerations of at least 10 bpm lasting at least 10 seconds (less than 32 weeks gestation)
- D. Four accelerations in 20 to 40 minutes
Correct Answer: A
Rationale: Step 1: Oligohydramnios indicates decreased amniotic fluid, which can lead to fetal hypoxia.
Step 2: Nonreactive NST suggests lack of appropriate fetal heart rate accelerations in response to fetal movement.
Step 3: Less than 2 accelerations in 20-40 minutes is consistent with nonreactive NST due to decreased fetal movement.
Step 4: Choice A is correct as it reflects the expected findings in a nonreactive NST scenario.
Summary:
- Choice B: The criteria for accelerations are too high for a nonreactive NST.
- Choice C: The criteria for accelerations are too low for a nonreactive NST.
- Choice D: Four accelerations in the given time frame do not correlate with a nonreactive NST.
A client has just received synthetic prostaglandins for the induction of labor. The nurse plans to monitor the client for which of the following side effects?
- A. Nausea and uterine tetany.
- B. Hypertension and vaginal bleeding.
- C. Urinary retention and severe headache.
- D. Bradycardia and hypothermia.
Correct Answer: A
Rationale: Synthetic prostaglandins can cause nausea and uterine tetany, which are common side effects. The nurse should monitor for these and other potential complications.
A client asks the nurse, “Could you explain how the baby’s blood and my blood separate at delivery?” Which of the following responses is appropriate for the nurse to make?
- A. “When the placenta is born, the circulatory systems separate.”
- B. “When the doctor clamps the cord, the blood stops mixing.”
- C. “The separation happens after the baby takes the first breath. The baby’s oxygen no longer has to come from you.”
- D. “The blood actually never mixes. Your blood supply and the baby’s blood supply are completely separate.”
Correct Answer: D
Rationale: The maternal and fetal blood supplies are separate throughout pregnancy, with oxygen and nutrients exchanged through the placenta.