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What is the best nursing intervention for a pregnant woman with hyperemesis gravidarum?
- A. Administer prescribed IV solution.
- B. Give oral rehydration solution.
- C. Encourage small, frequent meals.
- D. Offer ginger tea to reduce nausea.
Correct Answer: A
Rationale: The best nursing intervention for a pregnant woman with hyperemesis gravidarum is to administer the prescribed IV solution. Hyperemesis gravidarum is a severe form of nausea and vomiting during pregnancy that can lead to dehydration and electrolyte imbalances. Administering IV fluids helps in managing dehydration, replenishing electrolytes, and providing the necessary hydration for both the mother and the fetus. Giving oral rehydration solution (Choice B) may not be sufficient for severe cases of hyperemesis gravidarum where IV fluids are required. Encouraging small, frequent meals (Choice C) may not be effective as the woman may not be able to tolerate oral intake. Offering ginger tea (Choice D) is not the most appropriate intervention for hyperemesis gravidarum, as it may not provide adequate hydration or electrolyte balance needed in severe cases.
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When assessing a client who is at 12-weeks gestation, the LPN/LVN recommends that she and her husband consider attending childbirth preparation classes. When is the best time for the couple to attend these classes?
- A. At 16 weeks gestation.
- B. At 20 weeks gestation.
- C. At 24 weeks gestation.
- D. At 30 weeks gestation.
Correct Answer: D
Rationale: The best time for the couple to attend childbirth preparation classes is around 30 weeks gestation, which is during the third trimester. Attending classes at this time allows the couple to learn essential information and skills as labor and delivery are approaching, maximizing the benefit of the classes. Option A is too early in the second trimester, and the couple might forget important details by the time labor approaches. Option B is also early in the second trimester, and attending later allows for better preparation. Option C is still in the second trimester, and waiting until the third trimester provides more practical knowledge closer to delivery.
Why is complete bedrest necessary for a pregnant client with mitral stenosis Class III?
- A. Complete bedrest decreases oxygen needs and demands on the heart muscle tissue.
- B. We want your baby to be healthy, and this is the only way we can ensure that will happen.
- C. I know you're upset. Would you like to talk about some activities you could do while in bed?
- D. Labor is difficult, and you need to use this time to rest before assuming child-caring duties.
Correct Answer: A
Rationale: Complete bedrest is necessary for a pregnant client with mitral stenosis Class III to reduce the workload on the heart, lower oxygen consumption, and prevent complications associated with cardiac conditions like mitral stenosis. By remaining in bed, the client can help maintain cardiac function and promote a safer pregnancy outcome. Choice B is incorrect as it does not provide a specific reason related to the client's medical condition. Choice C is not addressing the medical necessity of bedrest for this particular client. Choice D is irrelevant and does not explain the importance of bedrest for a pregnant client with mitral stenosis Class III.
After administering the varicella vaccine to a 5-year-old child, which instruction should the nurse provide the child's parent?
- A. Chewable children's aspirin will not help prevent inflammation.
- B. Keep the child home for the next two days.
- C. Any fever should be monitored and reported if severe.
- D. Apply a cool pack to the injection site to reduce discomfort.
Correct Answer: D
Rationale: After receiving the varicella vaccine, applying a cool pack to the injection site can help reduce discomfort. This intervention is a simple and effective way to manage local reactions at the site of the vaccination, providing comfort to the child and potentially reducing swelling or pain. Choices A, B, and C are incorrect because chewable children's aspirin is not typically recommended after vaccination, keeping the child home is not necessary unless advised by a healthcare provider, and monitoring fever alone is not the primary instruction post-varicella vaccination.
During a well-child visit for their child, one of the parents with an autosomal dominant disorder tells the nurse, 'We don't plan on having any more children, since the next child is likely to inherit this disorder.' How should the nurse respond?
- A. Explain that the risk of inheriting the disorder decreases by 50% with each child the couple has.
- B. Acknowledge that the next child will inherit the disorder since the first child did not.
- C. Encourage the couple to reconsider their decision since the inheritance pattern may be sex-linked.
- D. Confirm that there is a 50% chance of their future children inheriting the disorder.
Correct Answer: D
Rationale: Confirming that there is a 50% chance of their future children inheriting the disorder is the correct response in this situation. Autosomal dominant disorders have a 50% chance of being passed on to each child. Providing accurate genetic counseling is essential to help the parents make informed decisions about family planning. Choices A, B, and C are incorrect. Choice A is inaccurate because the risk of inheriting an autosomal dominant disorder remains at 50% for each child regardless of the number of children the couple has. Choice B is not appropriate as it does not provide helpful information or support to the parents. Choice C is misleading because autosomal dominant disorders follow a specific inheritance pattern and are not sex-linked.
What is the most important assessment for the healthcare provider to conduct following the administration of epidural anesthesia to a client who is at 40-weeks gestation?
- A. Maternal blood pressure.
- B. Level of pain sensation
- C. Station of presenting part.
- D. Variability of fetal heart rate.
Correct Answer: A
Rationale: Following the administration of epidural anesthesia, the most crucial assessment for the healthcare provider to conduct is monitoring maternal blood pressure. Epidural anesthesia can lead to hypotension as a common side effect, which can have significant implications for both the mother and the fetus. Therefore, close monitoring of maternal blood pressure is essential to detect and manage any hypotensive episodes promptly. Choices B, C, and D are important assessments during labor and delivery, but in this specific scenario of post-epidural anesthesia, monitoring maternal blood pressure takes precedence due to the potential risk of hypotension.