Nokea
Which assessment finding suggests that the laboring client's
- B. Reflex grade 0
- C. Urine output 60
- D. Generalized seizure
Correct Answer: D
Rationale: The correct answer is D, Generalized seizure. During labor, a generalized seizure is a critical finding that indicates eclampsia, a severe complication of pregnancy characterized by seizures, hypertension, and proteinuria. This requires immediate medical intervention to prevent harm to the mother and baby. Reflex grade 0 (choice B) is not a typical assessment finding during labor, and it does not indicate any immediate life-threatening condition. Urine output of 60 (choice C) is within the normal range and does not suggest any immediate critical issue. Therefore, choice D is the correct answer due to the urgency and severity of the condition it represents.
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A woman is 16 weeks pregnant and she had cramping backache and mild bleeding for the past 3 days. The HCP determines she is dilated 2cm, 10% effaced, membranes intact. She's crying and saying to the nurse is my baby going to be okay? In addition to acknowledging the patient's fear the nurse should also say:
- A. Your cervix has begun to dilate, this is a serious sign, we will continue to monitor you and the baby for now
- B. I really can't say but when your physicians arrive, I'll ask her talk to you about it
- C. You baby will be fine, we will start an IV and get this stopped in no time at all
- D. You are going to miscarry, but you should be relieved because most miscarriages are the result of abnormalities in the fetus
Correct Answer: A
Rationale: Step 1: Acknowledge the patient's fear and anxiety.
Step 2: Provide a clear and honest response regarding the situation.
Step 3: Explain the significance of cervical dilation at 16 weeks.
Step 4: Assure the patient that they will be closely monitored.
Step 5: Offer support and comfort to the patient.
Summary:
Choice A is correct because it addresses the patient's concerns, acknowledges the seriousness of the situation, provides information about cervical dilation, and reassures the patient about monitoring. Choices B, C, and D are incorrect because they do not provide accurate information or address the situation appropriately, which could further distress the patient.
A nurse is caring for a client who experienced a cesarean birth due to dysfunctional labor. The client states that she is disappointed that she did not have natural childbirth. Which of the following responses should the nurse make?
- A. "It sounds like you are feeling sad that things didn't go as planned."
- B. "At least you know you have a healthy baby."
- C. "Maybe next time you can have a vaginal delivery."
- D. "You can resume sexual relations sooner than if you had delivered vaginally."
Correct Answer: A
Rationale: Step 1: Empathy - The nurse acknowledges the client's feelings of disappointment, showing empathy and understanding.
Step 2: Validation - By stating "It sounds like you are feeling sad that things didn't go as planned," the nurse validates the client's emotions, making her feel heard and supported.
Step 3: Therapeutic Communication - This response encourages the client to express her feelings further, promoting open communication and trust in the nurse-client relationship.
Summary:
Choice B is incorrect as it dismisses the client's emotional concerns and focuses solely on the baby's health. Choice C is incorrect as it minimizes the client's current experience and may increase feelings of inadequacy. Choice D is incorrect as it is not relevant to the client's emotional needs and may be perceived as insensitive.
A nurse is giving post-op teaching to a person after a surgical abortion. What education should be provided?
- A. Report bleeding that is heavy, soaks more than two pads per hour for 2 hours.
- B. You can resume vaginal coitus the next day.
- C. You do not need to return to the clinic for follow-up.
- D. You should use tampons if your bleeding is heavy.
Correct Answer: A
Rationale: The correct answer is A because heavy bleeding post-surgical abortion can indicate a complication like hemorrhage, so prompt reporting is crucial. Choice B is incorrect as resuming vaginal intercourse too soon can increase the risk of infection. Choice C is incorrect because follow-up care is essential to monitor for complications. Choice D is incorrect as tampons should be avoided to reduce the risk of infection. In summary, choice A is correct as it prioritizes patient safety and early detection of complications.
The nurse is assessing a client in the third trimester with suspected gestational diabetes. What symptom is most concerning?
- A. Increased thirst and urination.
- B. Fasting blood glucose of 100 mg/dL.
- C. Weight gain of 1 pound in a week.
- D. Proteinuria of +1.
Correct Answer: A
Rationale: The correct answer is A: Increased thirst and urination. In gestational diabetes, increased thirst and urination can indicate uncontrolled blood sugar levels, which can harm the fetus. This symptom suggests hyperglycemia and requires immediate intervention.
B: Fasting blood glucose of 100 mg/dL is within the normal range for pregnancy and not concerning.
C: Weight gain of 1 pound in a week can be normal in the third trimester and not specific to gestational diabetes.
D: Proteinuria of +1 is more concerning for preeclampsia rather than gestational diabetes.
Which intervention should the nurse prioritize for a pregnant client with placenta previa?
- A. Monitor the client for contractions
- B. Prepare for immediate cesarean delivery
- C. Monitor for signs of fetal distress
- D. Encourage the client to remain in bed rest
Correct Answer: B
Rationale: The correct answer is B: Prepare for immediate cesarean delivery. Placenta previa is a condition where the placenta partially or completely covers the cervix, which can lead to life-threatening bleeding during labor. Immediate cesarean delivery is the priority to prevent maternal and fetal complications. Monitoring for contractions (A) is important but not the priority. Monitoring for fetal distress (C) is crucial but not the immediate intervention. Encouraging bed rest (D) may be recommended but is not the priority intervention in placenta previa.