Nokea
The nurse suspects that a client has an early sign of ectopic
- B. Abdominal pain
- C. Vaginal spotting or light bleeding
- D. Pelvic pain
Correct Answer: C
Rationale: Vaginal spotting or light bleeding is one of the early signs of an ectopic pregnancy. Ectopic pregnancy occurs when a fertilized egg implants outside the uterus, most commonly in the fallopian tube. The presence of vaginal spotting or light bleeding may indicate the implantation of the fertilized egg in a location other than the uterus, leading to the suspicion of an ectopic pregnancy. It is essential for the nurse to recognize this early sign and promptly assess the client for further evaluation and intervention to prevent complications such as rupture and severe bleeding that can be life-threatening.
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A client at 32 weeks' gestation reports regular uterine contractions every 10 minutes. What is the nurse's priority action?
- A. Administer tocolytic medication as prescribed.
- B. Perform a sterile vaginal examination.
- C. Assess for cervical changes and fetal heart rate.
- D. Encourage ambulation to relieve discomfort.
Correct Answer: C
Rationale: Assessing cervical changes and fetal heart rate is essential to determine whether the client is in preterm labor.
A client in labor receiving an epidural reports feeling lightheaded and nauseous. What is the nurse's priority intervention?
- A. Administer antiemetics as prescribed.
- B. Check maternal blood pressure.
- C. Increase the oxytocin infusion rate.
- D. Encourage the client to lie on her back.
Correct Answer: B
Rationale: Lightheadedness and nausea can be signs of hypotension, a common side effect of epidural anesthesia.
The perinatal nurse assisting with establishing lactation is aware that acute mastitis can be minimized by
- A. Proper breastfeeding techniques
- B. Washing with mild soap and water once a day
- C. Wearing a supportive bra 24h
- D. Wearing a nipple shield first few days of breastfeeding
Correct Answer: A
Rationale: Acute mastitis is inflammation of the breast tissue that may result from milk stasis, inadequate milk removal, or bacteria entering the breast tissue through cracks in the nipple. One of the key ways to prevent acute mastitis is by ensuring proper breastfeeding techniques. This includes ensuring a good latch to allow for effective milk removal, practicing frequent and complete emptying of the breasts, and alternating the position of the baby during feeding to ensure all parts of the breast are drained. Proper breastfeeding techniques help to prevent milk stasis and reduce the risk of developing mastitis.
A nurse is providing dietary teaching for a client who is at 29 weeks of gestation and has phenylketonuria. Which of the following suggested foods should the nurse include in the teaching?
- A. A peanut butter sandwich on wheat bread.
- B. A sliced apple and red grapes.
- C. A chocolate chip cookie with a glass of skim milk.
- D. A scrambled egg with cheddar cheese.
Correct Answer: B
Rationale: Phenylketonuria (PKU) is a genetic disorder where the body cannot metabolize phenylalanine, an amino acid found in protein-containing foods. Patients with PKU need to follow a strict low-phenylalanine diet to prevent the buildup of phenylalanine in the body. Fruits like apples and grapes are low in protein and contain minimal phenylalanine, making them suitable choices for individuals with PKU. The other options listed contain higher amounts of protein and phenylalanine, such as peanut butter, chocolate chip cookies, milk, scrambled eggs, and cheese, which should be avoided by individuals with PKU.
The nurse is educating a client about postpartum care. What statement indicates the need for further teaching?
- A. I will call my doctor if I have a fever.
- B. It is normal to have heavy bleeding for two weeks.
- C. I will avoid lifting heavy objects.
- D. Breast tenderness is common when my milk comes in.
Correct Answer: B
Rationale: Heavy bleeding for two weeks is not normal and may indicate postpartum complications.