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When a client states, 'My water just broke,' what is the nurse's priority intervention?
- A. Perform Nitrazine testing.
- B. Assess the fluid.
- C. Check cervical dilation.
- D. Begin FHR monitoring.
Correct Answer: D
Rationale: The correct answer is D: Begin FHR monitoring. This is the priority intervention because assessing the fetal heart rate (FHR) helps determine the well-being of the baby after the water breaking. Monitoring the FHR can indicate if the baby is in distress and prompt further actions if needed. Performing Nitrazine testing (choice A) is used to confirm if the fluid is amniotic fluid, but FHR monitoring takes precedence. Assessing the fluid (choice B) is important but not as urgent as monitoring the FHR. Checking cervical dilation (choice C) is not the priority as ensuring the baby's well-being through FHR monitoring is crucial in this situation.
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When developing an educational program for adolescents about nutrition during the third trimester of pregnancy, which of the following statements should be included?
- A. Consume three to four servings of dairy each day.
- B. Increase daily caloric intake by 600 to 700 calories.
- C. Limit daily sodium intake to less than 1 gram.
- D. Increase protein intake to 40 to 50 grams per day.
Correct Answer: A
Rationale: The correct answer is A: Consume three to four servings of dairy each day. During the third trimester of pregnancy, calcium needs increase to support the baby's bone development. Dairy products are a rich source of calcium. Adolescents are still growing themselves, so adequate calcium intake is crucial for both the mother and baby.
B: Increasing caloric intake by 600 to 700 calories is not specific to the third trimester and may lead to excessive weight gain, which can be harmful.
C: Limiting sodium intake to less than 1 gram is not necessary during pregnancy, and some sodium is required for maintaining fluid balance.
D: Increasing protein intake to 40 to 50 grams per day is important, but it is not specific to the third trimester and may vary based on individual needs.
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.
A healthcare professional is preparing to collect a blood specimen from a newborn via a heel stick. Which of the following techniques should the professional use to help minimize the pain of the procedure for the newborn?
- A. Apply a cool pack to the heel for 10 minutes prior to the puncture.
- B. Request a prescription for IM analgesic.
- C. Use a manual lancet to pierce the skin.
- D. Place the newborn skin-to-skin on the mother's chest.
Correct Answer: D
Rationale: The correct answer is D: Place the newborn skin-to-skin on the mother's chest. This technique promotes bonding, warmth, and comfort, which can help minimize the newborn's pain perception during the procedure. Skin-to-skin contact releases oxytocin, which has analgesic effects. It also provides emotional support and reduces stress for both the newborn and the mother.
A, applying a cool pack, may cause vasoconstriction and increase pain perception. B, requesting an IM analgesic, is not typically necessary for a routine heel stick and may have potential adverse effects. C, using a manual lancet, does not address the emotional and psychological aspects of pain perception in newborns.
A nurse at an antepartum clinic is caring for a client who is at 4 months of gestation. The client reports continued nausea, vomiting, and scant, prune-colored discharge. The client has experienced no weight loss and has a fundal height larger than expected. Which of the following complications should the nurse suspect?
- A. Hyperemesis gravidarum
- B. Threatened abortion
- C. Hydatidiform mole
- D. Preterm labor
Correct Answer: C
Rationale: The correct answer is C: Hydatidiform mole. At 4 months of gestation, prune-colored discharge indicates possible passage of vesicular tissue characteristic of a molar pregnancy. This, along with continued nausea, vomiting, and larger fundal height, are signs of a hydatidiform mole. Hyperemesis gravidarum (A) typically involves severe nausea and vomiting leading to weight loss, which the client did not experience. Threatened abortion (B) presents with vaginal bleeding and cramping, not prune-colored discharge. Preterm labor (D) is characterized by regular contractions leading to cervical changes, not the symptoms described.
A client who is at 6 weeks of gestation is being educated about common discomforts of pregnancy. Which of the following findings should the individual include? (Select all that apply)
- A. Breast tenderness
- B. Urinary frequency
- C. Epistaxis
- D. All of the above
Correct Answer: D
Rationale: The correct answer is D: All of the above. At 6 weeks of gestation, common discomforts include breast tenderness due to hormonal changes, urinary frequency from increased blood flow to kidneys, and epistaxis (nosebleeds) due to increased blood volume and vessel fragility. Therefore, all options are relevant and should be included in the education. Other choices are incorrect because they do not encompass all the common discomforts experienced during early pregnancy.