Nokea
A client at 28 weeks' gestation reports feeling fewer fetal movements. What should the nurse recommend first?
- A. Perform a nonstress test.
- B. Drink a glass of juice and lie down.
- C. Notify the healthcare provider immediately.
- D. Schedule an ultrasound.
Correct Answer: B
Rationale: Drinking juice and lying down can stimulate fetal movement and help evaluate whether further action is needed.
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The nurse is caring for a pregnant client with a diagnosis of gestational diabetes. What finding indicates the need for immediate intervention?
- A. Blood sugar of 130 mg/dL after a meal.
- B. Fasting blood sugar of 95 mg/dL.
- C. Presence of ketones in the urine.
- D. Client reports increased thirst.
Correct Answer: C
Rationale: Ketones in the urine indicate poor glucose control and possible ketoacidosis, requiring urgent medical attention.
A patient calls and says she used her diaphragm on Saturday night at 8:00 p.m., again on Sunday morning at 2:00 a.m., and again at 8:00 a.m. She is wondering when she can safely remove it while still having effective contraception. What is the nurse’s best response?
- A. 10:00 a.m. Sunday
- B. 2:00 p.m. Sunday
- C. 10:00 p.m. Sunday
- D. 8:00 a.m. Monday
Correct Answer: D
Rationale: In general, a diaphragm should be left in place for at least 6 hours after intercourse but no more than 24 hours. Based on the patient's usage times on Saturday night at 8:00 p.m., Sunday morning at 2:00 a.m., and Sunday morning at 8:00 a.m., she can safely remove the diaphragm on Monday morning at 8:00 a.m. This ensures she has used it for the necessary timeframe for effective contraception.
A nurse is caring for a client who is 1 day postpartum and is taking a sitz bath. To determine the client's tolerance of the procedure, which of the following assessments should the nurse perform?
- A. Bladder distention
- B. Pulse rate
- C. Respiratory rate
- D. Color of lochia
Correct Answer: B
Rationale: The nurse should assess the client's pulse rate to determine the client's tolerance of the sitz bath. An elevated pulse may indicate that the sitz bath is causing discomfort or stress to the client. Monitoring the pulse rate is essential to ensure the client's safety and comfort during the procedure. Bladder distention, respiratory rate, and color of lochia are important assessments in postpartum care but are not specifically related to determining the client's tolerance of a sitz bath.
A woman is being treated for preterm labor with magnesium
- A. The nurse is concerned that the patient is experiencing early drug toxicity. Which assessment finding by the nurse indicates early toxicity?
- B. Patellar reflexes are weak and absent
- C. RR 16
- D. Fetal HR 120
Correct Answer: E
Rationale: The correct assessment finding that indicates early toxicity related to magnesium sulfate administration is the patient complaining of feeling flushed and warm. These symptoms could indicate that the patient is experiencing magnesium toxicity, which can lead to vasodilation and hypotension. Other signs of magnesium toxicity include decreased deep tendon reflexes, respiratory depression, and loss of consciousness. It's essential for the nurse to recognize these early signs of toxicity and intervene promptly to prevent further complications.
Platypelloid pelvis
- A. Places the client as risk for dystocia
- B. Has an increased probability of cesarean section
- C. Has a flat shape that may impede fetal descent
- D. A Gynecoid pelvis is roomy and ideal for vaginal birth. An Anthropoid pelvis has an oval shape, and an android pelvis is heart shape.
Correct Answer: A
Rationale: A platypelloid pelvis is characterized by a flat shape with a shortened anteroposterior diameter, which can impede fetal descent during labor. This pelvic type is associated with an increased risk of dystocia, which is difficulty in childbirth due to inadequate progress of labor. The flat shape of the pelvis may lead to improper positioning of the baby, making it challenging for the fetus to navigate through the birth canal. This can result in prolonged labor, increased risk of birth injuries, and potential complications for both the mother and the baby. In some cases, it may necessitate interventions such as labor induction or cesarean delivery to ensure a safe outcome for the mother and the baby.