Nokea
Which client would be at greatest risk for developing
- A. Thick breast cancer?
- B. Wet/slippery with egg white consistency
- C. Client who had her first baby at the age of 24
- D. Client who did not breastfeed
Correct Answer: D
Rationale: Not breastfeeding has been identified as a risk factor for developing breast cancer. Breastfeeding has been shown to have a protective effect against breast cancer due to its impact on hormonal levels and breast tissue changes that occur during lactation. Therefore, compared to other options, the client who did not breastfeed would be at greater risk for developing breast cancer.
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The nurse is preparing a client for cesarean delivery. What is the priority nursing action?
- A. Obtain baseline vital signs.
- B. Insert an indwelling urinary catheter.
- C. Verify signed informed consent.
- D. Administer prophylactic antibiotics.
Correct Answer: C
Rationale: Ensuring informed consent is signed is a priority before any surgical procedure.
The nurse is caring for a client whose labor is being augmented with Pitocin. He or she recognizes that Pitocin should be stopped immediately if there is evidence of what?
- A. Fetal HR 180 without sense of variability
- B. Rupture of amniotic membrane
- C. Client needs to void
- D. Uterine contractions q8-10 minutes
Correct Answer: A
Rationale: Pitocin is a medication commonly used to induce or augment labor by stimulating uterine contractions. It is critical for the nurse to monitor the client closely for potential adverse effects. Fetal distress is a serious concern when Pitocin is being administered. A fetal heart rate of 180 beats per minute without variability may indicate fetal distress due to uteroplacental insufficiency. This is a sign of fetal hypoxia and warrants immediate intervention, including stopping the infusion of Pitocin, repositioning the mother, administering oxygen, and notifying the healthcare provider. It is crucial for the nurse to act promptly to ensure the safety and well-being of both the fetus and the mother.
The nurse is monitoring a pregnant client undergoing a nonstress test. What is a reassuring finding?
- A. Two accelerations in 20 minutes.
- B. Baseline fetal heart rate of 170 beats/minute.
- C. Decreased fetal movement.
- D. Variable decelerations.
Correct Answer: A
Rationale: Two accelerations within 20 minutes indicate a reactive and reassuring nonstress test result.
Which environment can assist a pregnant teen to achieve the task of establishing a stable identity?
- A. Home schooling
- B. Alternative education program
- C. School-based mothers' program
- D. Continuing mainstream high school classes
Correct Answer: C
Rationale: A school-based mothers' program can assist a pregnant teen in establishing a stable identity by providing specialized support and resources tailored to their unique needs. These programs typically offer academic assistance, childcare services, counseling, and parenting classes. By being in a supportive and understanding environment with other young mothers, the pregnant teen can feel accepted and supported, which can help boost her self-esteem and confidence. Additionally, these programs often focus on empowering young mothers to continue their education and set goals for their future, contributing to the development of a stable identity.
What does the nurse know about the definition of a family?
- A. Families are made up of couples with biological children.
- B. Families are created through marriage or birth.
- C. Families can be blended but are not called families.
- D. Families are made of kinships defined by the family.
Correct Answer: D
Rationale: Families are diverse and defined by the individuals involved, not limited to traditional structures.