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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The 22-year-old client, who is experiencing vaginal bleeding in the first trimester of pregnancy, fears that she has lost her baby at 8 weeks. Which definitive test result should indicate to the nurse that the client’s fetus has been lost?
- A. Falling beta human chorionic gonadotropin (BHCG) measurement
- B. Low progesterone measurement
- C. Ultrasound showing a lack of fetal cardiac activity
- D. Ultrasound determining crown-rump length
Correct Answer: C
Rationale: Ultrasound is used to determine if the fetus has died. The lack of fetal heart activity in a pregnancy over 6 weeks determines a fetal loss. Falling BHCG levels do not conclusively diagnose fetal demise. Low progesterone levels do not conclusively diagnose fetal demise. Crown-rump length determines only the fetal gestational age.
The client, whose parity is 1, had a vaginal delivery 6 days ago and arrived home yesterday after treatment for endometritis. The home health nurse visits the client and plans teaching after seeing which most concerning item in the client’s bathroom?
- A. A box of tampons on the floor outside of the shower stall.
- B. Loofa bath sponge sitting on the seat of the shower stall.
- C. Damp towel bunched on the towel bar and near the floor.
- D. Can of bathroom cleaner on the floor of the shower stall.
Correct Answer: A
Rationale: The nurse should plan teaching about the use of tampons during postpartum. The tampon may irritate or dry the vagina, holds lochia in the body, and increases the risk of infection. The client should be instructed to wear a peripad. Loofas or bath sponges for bathing the body postpartum are not contraindicated. While it is a good idea to hang towels neatly so that they dry more rapidly and reduce mold growth, this is not a priority for teaching. The bathroom cleaner would be dangerous to an older child who is more mobile, but the client’s parity is 1. The client would be wise to start considering safety issues by placing this out of reach, but this is not the priority teaching item.
The nurse is caring for the pregnant client whose FHR tracing reveals a reduction in variability over the last 40 minutes. The client has had occasional decelerations after the onset of a contraction that did not resolve until the contraction was over. The client suddenly has a prolonged deceleration that does not resolve, and the nurse immediately intervenes by calling for assistance. Place the nurse’s interventions in the sequence that they should occur.
- A. Administer oxygen via facemask
- B. Have the HCP paged if the prolonged decelerations have not resolved.
- C. Place an indwelling urinary catheter in anticipation of emergency cesarean birth if the heart rate remains low.
- D. Increase the rate of the intravenous (IV) fluids
- E. Assist the client into a different position
- F. Prepare for a vaginal examination and fetal scalp stimulation
Correct Answer: E,A,D,B,F,C
Rationale: Assist the client into a different position should be first. Repositioning is an attempt to increase the FHR in case of cord obstruction. Administer oxygen via facemask is next to increase oxygenation to the fetus. Increase the rate of the IV fluids next to treat possible hypotension, the most common cause of fetal bradycardia. Have the HCP paged if the prolonged decelerations have not resolved. The immediate focus should be on attempting to relieve the prolonged decelerations. Prepare for a vaginal examination and fetal scalp stimulation. This is performed to rule out cord prolapse and to provide stimulation to the fetal head. Place an indwelling urinary catheter in anticipation of emergency cesarean birth if the HR remains low.
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.