Nokea
What information should the nurse also include about the side effects of iron supplementation?
- A. You may notice that your stools will be black.
- B. Your teeth will become stained.
- C. Vomiting is likely to occur.
- D. You may have diarrhea several times per day.
Correct Answer: A
Rationale: Black stools are a common side effect of iron supplements due to unabsorbed iron, unlike the other options.
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Which cultural consideration should the nurse include in prenatal education?
- A. Respect client's dietary preferences and beliefs
- B. Ignore cultural practices
- C. Standardize all education materials
- D. Avoid discussing family roles
Correct Answer: A
Rationale: Respecting the client's dietary preferences and cultural beliefs ensures culturally sensitive and effective prenatal education.
The client who is 32 weeks pregnant asks how the nurse will monitor the baby’s growth and determine if the baby is “really okay.” Which assessments should the nurse identify for evaluating the fetus for adequate growth and viability? Select all that apply.
- A. Auscultate maternal heart tones.
- B. Measure the height of the fundus.
- C. Measure the client’s abdominal girth.
- D. Complete a third-trimester ultrasound.
- E. Auscultate the fetal heart tones (FHT).
Correct Answer: B,E
Rationale: Adequate fetal growth is evaluated by measuring the fundal height. Auscultating the FHT assesses fetal viability. The presence of fetal (not maternal) heart tones starting at around 10-12 weeks is a standard to assess fetal growth and viability. The abdominal circumference does not provide information about fetal growth. The increase in abdominal girth could be due to weight gain or fluid retention, not just growth of the baby. Third-trimester ultrasound is neither routine nor advised for routine prenatal care because of the added cost and potential risk to the fetus.
Which of the following should the nurse plan to have available when providing nursing care to this client? Select all that apply.
- A. I.V. start kit
- B. An intake and output record
- C. Oxygen and face mask
- D. Cardiac monitor
- E. A consent for a blood transfusion
- F. A suction machine
Correct Answer: A,B,C,F
Rationale: Hyperemesis gravidarum with dehydration requires I.V. fluids, intake/output monitoring, oxygen if needed, and suction for vomiting.
The client had a D&C for treating an incomplete spontaneous abortion. Which statements should the nurse include when preparing the client for discharge the same day? Select all that apply.
- A. “Return for a blood transfusion if bleeding continues to be dark red.”
- B. “Intravenous antibiotics will be prescribed every 8 hours for two days.”
- C. “I can make a referral to a pregnancy loss support group if you like.”
- D. “You need to use contraceptives to avoid getting pregnant for one year.”
- E. “Someone should remain with you at home for the first 12 to 24 hours.”
Correct Answer: C,E
Rationale: The client who had an incomplete spontaneous abortion may experience grief and loss. The nurse should offer to do a referral to a pregnancy loss support group to provide ongoing support after hospital discharge. A D&C is usually performed on an outpatient basis if there are no complications, and the client can return home a few hours after the procedure. Someone should remain with the client to ensure that she is safe and no complications develop. Dark red blood does not necessarily indicate the need for a blood transfusion; it could be old blood. The client should notify the HCP if experiencing heavy bleeding following the D&C. A D&C for treating incomplete spontaneous abortion does not require the routine administration of IV antibiotics. There is no medical need for the client who had a spontaneous abortion to avoid pregnancy for one year.
Which response by the nurse addresses the client's anxiety about childbirth?
- A. Your anxiety is normal, and we can discuss coping strategies like breathing exercises.
- B. You should not be anxious; childbirth is a natural process.
- C. Anxiety will harm your baby, so you need medication.
- D. Ignore your anxiety; it will go away after delivery.
Correct Answer: A
Rationale: Acknowledging anxiety as normal and offering coping strategies like breathing exercises supports the client emotionally.