Nokea
What is the most appropriate statement for a nurse to make to a client who has recently experienced a perinatal death?
- A. It must be a comfort to know you have another child.
- B. I'm sad for you.
- C. There is usually something wrong with the baby.
- D. You will always have an angel in heaven.
Correct Answer: B
Rationale: The correct answer is B: "I'm sad for you." This response shows empathy and acknowledges the client's feelings without making assumptions or providing false reassurance. It validates the client's emotions and offers support.
Incorrect choices:
A: This statement assumes the client's feelings and may not be comforting.
C: This statement is insensitive and can cause unnecessary guilt or blame.
D: While well-intentioned, this statement may not align with the client's beliefs and can be dismissive of their grief.
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During an assessment, a client at 26 weeks of gestation presents with which of the following clinical manifestations that should be reported to the provider?
- A. Leukorrhea
- B. Supine hypotension
- C. Periodic numbness of the fingers
- D. Decreased urine output
Correct Answer: D
Rationale: The correct answer is D: Decreased urine output. At 26 weeks of gestation, decreased urine output can be a sign of potential complications like preeclampsia or dehydration, which require immediate medical attention to prevent harm to the mother and baby. Leukorrhea (choice A) is a common pregnancy symptom and not typically concerning. Supine hypotension (choice B) is a known issue in pregnancy but usually occurs later in the third trimester due to pressure on the vena cava when lying on the back. Periodic numbness of the fingers (choice C) can be related to carpal tunnel syndrome, which is common in pregnancy but not typically urgent at 26 weeks unless severe and persistent.
During a nonstress test for a pregnant client, a nurse uses an acoustic vibration device. The client inquires about its purpose. Which response should the nurse provide?
- A. It is used to stimulate uterine contractions.
- B. It will decrease the incidence of uterine contractions.
- C. It lulls the fetus to sleep.
- D. It awakens a sleeping fetus.
Correct Answer: D
Rationale: The correct answer is D because the acoustic vibration device is used during a nonstress test to wake up a sleeping fetus, ensuring that the baby is active and responsive during the test. This helps to assess the baby's well-being and monitor its heart rate patterns. Choice A is incorrect as the device does not stimulate uterine contractions. Choice B is incorrect as it does not decrease the incidence of contractions. Choice C is incorrect as the device does not lull the fetus to sleep, but rather ensures the fetus is awake and moving during the test.
A client who received carboprost for postpartum hemorrhage is being assessed by a nurse. Which of the following findings is an adverse effect of this medication?
- A. Hypertension
- B. Hypothermia
- C. Constipation
- D. Muscle weakness
Correct Answer: A
Rationale: The correct answer is A: Hypertension. Carboprost is a prostaglandin used to treat postpartum hemorrhage that can cause hypertension as an adverse effect due to its vasoconstrictive properties. This can lead to increased blood pressure, which should be monitored closely. Hypothermia (choice B) is not a common adverse effect of carboprost. Constipation (choice C) and muscle weakness (choice D) are also not typically associated with carboprost use. Monitoring blood pressure and signs of hypertension is crucial due to the potential adverse effects of carboprost.
An adolescent is being taught about levonorgestrel contraception by a school nurse. What information should the nurse include in the teaching?
- A. You should take the medication within 72 hours following unprotected sexual intercourse.
- B. Do not take this medication if you are on an oral contraceptive.
- C. If you do not start your period within 5 days of taking this medication, you will need a pregnancy test.
- D. One dose of this medication will prevent pregnancy for 14 days after taking it.
Correct Answer: A
Rationale: Step 1: Levonorgestrel is a type of emergency contraception that is most effective when taken within 72 hours after unprotected sex.
Step 2: Taking the medication within the specified time frame increases its effectiveness in preventing pregnancy.
Step 3: Thus, the nurse should emphasize to the adolescent the importance of taking the medication promptly after unprotected intercourse.
Step 4: This information is crucial for the adolescent to understand the time-sensitive nature of levonorgestrel contraception.
Summary:
- Choice B is incorrect because it provides contradictory information. Levonorgestrel can be taken even if the individual is on an oral contraceptive.
- Choice C is incorrect as starting a period is not a reliable indicator of pregnancy. A pregnancy test is recommended if there are concerns.
- Choice D is incorrect because levonorgestrel is a single-dose emergency contraception and does not provide protection for 14 days.
A client at 42 weeks of gestation is having an ultrasound. For which of the following conditions should the nurse prepare for an amnioinfusion? (Select all that apply)
- A. Oligohydramnios
- B. Hydramnios
- C. Fetal cord compression
- D. Polyhydramnios
Correct Answer: A
Rationale: Rationale: A client at 42 weeks of gestation is at risk for oligohydramnios, which is associated with decreased amniotic fluid levels. Amnioinfusion can be used to increase amniotic fluid volume to prevent fetal cord compression and facilitate fetal movement during labor.
Summary:
- B: Hydramnios (excessive amniotic fluid) does not require amnioinfusion.
- C: Fetal cord compression is a reason for amnioinfusion, not a condition to prepare for.
- D: Polyhydramnios (excessive amniotic fluid) does not typically require amnioinfusion unless there are complicating factors.