Nokea
When caring for a client receiving nifedipine for prevention of preterm labor, the nurse should monitor the client for which of the following manifestations?
- A. Blood-tinged sputum
- B. Dizziness
- C. Pallor
- D. Somnolence
Correct Answer: B
Rationale: The correct answer is B: Dizziness. Nifedipine is a calcium channel blocker that can cause hypotension, leading to dizziness. This is a common side effect and needs to be monitored to prevent falls or injury. Blood-tinged sputum (A) is not typically associated with nifedipine use. Pallor (C) is not a common manifestation of nifedipine side effects. Somnolence (D) is also not a common side effect of nifedipine. Dizziness is the most relevant and potentially harmful manifestation to monitor for in a client receiving nifedipine for preterm labor.
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A client who is 3 days postpartum is receiving education on effective breastfeeding. Which of the following information should the nurse include?
- A. Your milk will replace colostrum in about 10 days.
- B. Your breasts should feel firm after breastfeeding.
- C. Your newborn should urinate at least 10 times per day.
- D. Your newborn should appear content after each feeding.
Correct Answer: D
Rationale: The correct answer is D: Your newborn should appear content after each feeding. This is important as it indicates the baby is getting enough milk and is satisfied. If the baby appears content, it suggests effective breastfeeding. Choice A is incorrect as milk transition typically occurs within a few days, not 10. Choice B is incorrect as breasts feeling firm is not a reliable indicator of successful breastfeeding. Choice C is incorrect as the number of wet diapers is a better indicator of proper hydration, not just urination frequency.
A healthcare provider is reinforcing teaching with a client about a new prescription for medroxyprogesterone. Which of the following information should the provider include in the teaching? (Select all that apply)
- A. Weight fluctuations can occur.
- B. Irregular vaginal spotting can occur.
- C. You should increase your intake of calcium.
- D. All of the above
Correct Answer: D
Rationale: The correct answer is D because all options are relevant when teaching a client about medroxyprogesterone. A, weight fluctuations can occur due to hormonal changes. B, irregular vaginal spotting is a common side effect of medroxyprogesterone. C, increasing calcium intake is important to prevent bone density loss associated with long-term medroxyprogesterone use. Therefore, all options are essential for comprehensive client education. Other choices are incorrect because excluding any of these key points could lead to incomplete information and potential misunderstandings regarding the medication's effects and management.
When discussing intermittent fetal heart monitoring with a newly licensed nurse, which statement should a nurse include?
- A. Count the fetal heart rate for 15 seconds to determine the baseline.
- B. Auscultate the fetal heart rate every 5 minutes during the active phase of the first stage of labor.
- C. Count the fetal heart rate after a contraction to determine baseline changes.
- D. Auscultate the fetal heart rate every 30 minutes during the second stage of labor.
Correct Answer: C
Rationale: The correct answer is C because counting the fetal heart rate after a contraction helps determine baseline changes, which is essential for identifying fetal distress. This method allows for accurate assessment of fetal well-being in response to contractions. Choice A is incorrect as 15 seconds is not enough time to establish a baseline. Choice B is incorrect as auscultating every 5 minutes may not provide timely information during the active phase. Choice D is incorrect because auscultating every 30 minutes in the second stage may miss important changes in fetal status. Therefore, option C is the most appropriate choice for intermittent fetal heart monitoring.
A nurse is caring for a client who is at 40 weeks of gestation and is in early labor. The client has a platelet count of 75,000/mm3 and is requesting pain relief. Which of the following treatment modalities should the nurse anticipate?
- A. Epidural analgesia
- B. Naloxone hydrochloride
- C. Attention-focusing
- D. Pudendal nerve block
Correct Answer: C
Rationale: The correct answer is C: Attention-focusing. At 40 weeks gestation with a platelet count of 75,000/mm3, epidural analgesia is contraindicated due to the risk of epidural hematoma. Naloxone hydrochloride is an opioid antagonist used for opioid overdose, not for labor pain relief. Pudendal nerve block is used for local anesthesia during the second stage of labor, not for early labor pain relief. Attention-focusing techniques can help the client manage pain without pharmacological interventions, ensuring safety for both the client and the baby.
A client is reinforcing discharge teaching with a client who has premature rupture of membranes at 26 weeks of gestation. Which of the following instructions should the client include?
- A. Use a condom with sexual intercourse
- B. Avoid bubble bath solution when taking a tub bath
- C. Wipe from front to back when performing perineal hygiene
- D. Keep a daily record of fetal kick counts
Correct Answer: D
Rationale: The correct answer is D: Keep a daily record of fetal kick counts. This is important for monitoring fetal well-being, especially in cases of premature rupture of membranes. By counting fetal kicks daily, the client can assess fetal movements and report any changes promptly to healthcare providers. This helps in early detection of fetal distress or problems.
A: Using a condom with sexual intercourse is not relevant to the situation of premature rupture of membranes.
B: Avoiding bubble bath solution is important for preventing vaginal infections but not directly related to monitoring fetal well-being.
C: Wiping from front to back during perineal hygiene is a general hygiene practice and not specific to the situation of premature rupture of membranes.