Nokea
When a pregnant woman develops ptyalism, which guidance should the nurse provide?
- A. Chew gum or suck on lozenges between meals.
- B. Eat nutritious meals that provide adequate amounts of essential vitamins and minerals.
- C. Take short walks to stimulate circulation in the legs and elevate the legs periodically.
- D. Use pillows to support the abdomen and back during sleep.
Correct Answer: A
Rationale: The correct answer is A: Chew gum or suck on lozenges between meals. Ptyalism is excessive saliva production during pregnancy. Chewing gum or sucking on lozenges can help manage excessive saliva by promoting swallowing and reducing the sensation of saliva accumulation. This guidance addresses the symptom directly. Choices B, C, and D do not specifically address ptyalism. B focuses on nutrition, C on circulation, and D on physical comfort, which are important aspects of pregnancy but not directly related to managing ptyalism.
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A woman, who is in pain from a diagnosis of mastitis, has abruptly weaned her baby to a bottle. Her actions place the woman at high risk for which of the following?
- A. Mammary rupture.
- B. Postpartum psychosis.
- C. Supernumerary nipples.
- D. Breast abscess.
Correct Answer: D
Rationale: Abrupt weaning can lead to milk stasis, increasing the risk of a breast abscess due to bacterial infection.
A nurse is providing prenatal education to a patient who is 8 weeks pregnant. The nurse informs the patient that the developing fetus is most vulnerable to teratogens during what trimester of pregnancy?
- A. first
- B. second
- C. third
- D. fourth
Correct Answer: A
Rationale: The correct answer is A (first trimester). During the first trimester (weeks 1-12), the developing fetus is most vulnerable to teratogens as major organs are forming. Exposure to teratogens during this critical period can lead to severe birth defects. In contrast, the second trimester (weeks 13-26) is a period of rapid growth and development, but most major organs have already formed. The third trimester (weeks 27-birth) focuses on further growth and maturation, with reduced risk of teratogen-related birth defects. The fourth trimester is not a valid option as pregnancy only consists of three trimesters.
A nurse hears a co-worker state that anybody could be a nurse since it is so automated with infusion devices and electronic monitoring; technology is doing the work. What is the nurse’s best response?
- A. Technology use has to be combined with nursing judgment.
- B. The focus of effective nursing care is technology.
- C. If it’s so easy, why don’t you do it?
- D. That is true in the 20th century.
Correct Answer: A
Rationale: In many ways, technology makes work easier, but it does not replace nursing judgment. Technology does not replace your critical eye and clinical judgment. Most importantly, it is essential to remember that the focus of nursing care is not the machine or the technology; it is the patient.
The nurse would be concerned that a 26-week-gravid client is carrying an unwanted pregnancy when the client makes which of the following statements?
- A. The baby hasn't started to move yet.'
- B. My back aches every night when I get home from work.'
- C. I am finding it very hard always to eat the right things.'
- D. I am no longer able to wear my old clothes.'
Correct Answer: A
Rationale: Lack of fetal movement at 26 weeks could indicate a problem with the pregnancy or that the client is not emotionally connected to the pregnancy, suggesting it may be unwanted.
The nurse reports a nonreactive NST to the physician. The physician orders vibroacoustic stimulation. Which does the nurse understand the appropriate application for the vibroacoustic stimulation to be? Select all that apply.
- A. Clap loudly by the fetal head
- B. Apply a sterile drape to abdomen prior to stimulation
- C. Apply the artificial larynx stimulus by the fetal head
- D. Limit the use of the artificial larynx stimulus to three times
Correct Answer: C
Rationale: The correct answer is C: Apply the artificial larynx stimulus by the fetal head. Vibroacoustic stimulation involves using sound waves to stimulate the fetus and provoke a response, particularly in cases of nonreactive nonstress test (NST). By applying the artificial larynx stimulus near the fetal head, the nurse ensures direct and effective stimulation of the fetus. This method has been found to be safe and effective in improving fetal heart rate reactivity.
Incorrect Choices:
A: Clap loudly by the fetal head - This is not an appropriate method for vibroacoustic stimulation as it may not provide the controlled and targeted stimulation needed.
B: Apply a sterile drape to abdomen prior to stimulation - This is not necessary for vibroacoustic stimulation and does not contribute to its effectiveness.
D: Limit the use of the artificial larynx stimulus to three times - There is no specific limit to the number of times vibroacoustic stimulation can be applied, as it depends on the