Nokea
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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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 client at 40 weeks of gestation is experiencing contractions every 3 to 5 minutes, becoming stronger. A vaginal exam by the registered nurse reveals the client's cervix is 3 cm dilated, 80% effaced, and -1 station. The client requests pain medication. Which of the following actions should the nurse prepare to take? (Select all that apply)
- A. Provide ice chips.
- B. Insert an indwelling urinary catheter.
- C. Administer opioid analgesic medication.
- D. Provide ice chips.
Correct Answer: C
Rationale: The correct action is to administer opioid analgesic medication (Choice C). At 40 weeks gestation with contractions every 3-5 minutes, 3 cm dilated, 80% effaced, and -1 station, the client is in active labor. Pain medication is appropriate to manage discomfort during labor. Opioid analgesics can help reduce pain intensity while still allowing the client to remain alert and participate in labor. Ice chips (Choice A and D) are not directly related to pain management in labor. Inserting a urinary catheter (Choice B) is not indicated unless there are specific concerns about bladder distention.
When reviewing postpartum nutrition needs with breastfeeding clients, which statement indicates an understanding of the teaching?
- A. I am glad I can have my morning coffee.
- B. I should take folic acid to increase my milk supply.
- C. I will continue adding 330 calories per day to my diet.
- D. I will continue my calcium supplements because I don't like milk.
Correct Answer: D
Rationale: The correct answer is D because it demonstrates an understanding of the importance of calcium intake for breastfeeding mothers. Calcium is essential for both the mother's health and the baby's bone development. Continuing calcium supplements shows a commitment to meeting nutritional needs.
Incorrect choices:
A: Having coffee is fine, but it's not directly related to postpartum nutrition needs.
B: Folic acid is important for pregnancy but not specifically for increasing milk supply.
C: While additional calories are needed during breastfeeding, the specific amount varies and is not always 330 calories per day.
A nurse in a health clinic is reinforcing teaching about contraceptive use with a group of clients. Which of the following client statements demonstrates understanding?
- A. Using a water-soluble lubricant with condoms can help prevent breakage and ensure effectiveness in preventing pregnancy and STIs.
- B. A diaphragm should be removed 2 hours after intercourse.
- C. Oral contraceptives can worsen a case of acne.
- D. A contraceptive patch is replaced once a month.
Correct Answer: A
Rationale: The correct answer is A because using a water-soluble lubricant with condoms can indeed help prevent breakage and maintain effectiveness in preventing pregnancy and STIs. Water-based lubricants are safe to use with condoms as they do not weaken the latex.
Option B is incorrect as a diaphragm should be left in place for at least 6 hours after intercourse, not removed after 2 hours. Option C is also incorrect as oral contraceptives are known to improve acne in many cases. Option D is incorrect as a contraceptive patch is typically replaced weekly, not monthly.
A client with pregestational type 1 diabetes mellitus is being taught by a nurse about management during pregnancy. Which of the following statements by the client indicates an understanding of the teaching?
- A. I should aim to maintain my fasting blood glucose between 100 and 120.
- B. I should engage in moderate exercise for 30 minutes if my blood glucose is 250 or higher.
- C. I will continue taking my insulin if I experience nausea and vomiting.
- D. I will avoid exercise if my blood glucose exceeds 250.
Correct Answer: C
Rationale: The correct answer is C because continuing to take insulin during nausea and vomiting is crucial for maintaining blood glucose control in clients with diabetes. Nausea and vomiting can lead to decreased food intake, risking hypoglycemia if insulin is not adjusted.
Choice A is incorrect because fasting blood glucose levels should ideally be maintained between 60-90 mg/dL in pregnant clients with diabetes for optimal outcomes, not 100-120 mg/dL.
Choice B is incorrect because engaging in moderate exercise when blood glucose is high (250 or higher) can exacerbate hyperglycemia rather than help in lowering blood glucose levels.
Choice D is incorrect because avoiding exercise when blood glucose exceeds 250 is not recommended. Exercise can help lower blood glucose levels and improve insulin sensitivity.