Nokea
Which information is most important for the nurse to gather when a client is admitted to the unit in labor?
- A. Name of the support person
- B. Medical problems or complications
- C. Fluid preferences
- D. Amount of weight gained during the pregnancy
Correct Answer: B
Rationale: The correct answer is B: Medical problems or complications. This information is crucial for assessing the client's risk status and determining appropriate care during labor. Knowing the medical history helps identify potential complications that may arise and allows the nurse to plan for necessary interventions. Gathering information on the support person (choice A) is important but not as critical as the client's medical history. Fluid preferences (choice C) and weight gained during pregnancy (choice D) are relevant but do not directly impact the immediate care needed during labor. Without additional choices provided, it is evident that medical problems or complications (choice B) takes precedence in ensuring the safety and well-being of both the client and the baby.
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A nurse in the clinic instructs a primigravida about the danger signs of pregnancy. The client demonstrates understanding of the instructions, stating she will notify the physician if which sign occurs?
- A. White vaginal discharge
- B. Dull backache
- C. Frequent,urgent urination
- D. Abdominal pain
Correct Answer: D
Rationale: The correct answer is D: Abdominal pain. Abdominal pain is a significant danger sign in pregnancy that could indicate various complications such as ectopic pregnancy, placental abruption, or preterm labor. Prompt medical evaluation is crucial to ensure the health of both the mother and the baby. White vaginal discharge (A) is not necessarily a danger sign unless it is accompanied by other symptoms like itching or a foul smell. Dull backache (B) is common in pregnancy and usually not a cause for concern unless severe or accompanied by other symptoms. Frequent, urgent urination (C) is a common symptom in pregnancy due to increased pressure on the bladder and is not typically a danger sign unless associated with pain or burning.
A woman at 42 weeks gestation enters the hospital for induction of labor. Since the infant is postterm, which complications should the nurse anticipate when planning for the delivery?
- A. Cephalopelvic disproportion and hypothermia
- B. Asphyxia and meconium aspiration
- C. Intraventricular hemorrhage and dry,cracked skin
- D. Hyperbilirubinemia and hypocalcemia
Correct Answer: B
Rationale: The correct answer is B: Asphyxia and meconium aspiration. At 42 weeks gestation, the risk of perinatal asphyxia increases due to decreased placental function. Meconium aspiration can occur if the fetus passes stool in utero, leading to respiratory distress. The other choices are not directly related to postterm pregnancy complications. Cephalopelvic disproportion and hypothermia (Choice A) are not specific to postterm pregnancy. Intraventricular hemorrhage and dry, cracked skin (Choice C) are not commonly associated with postterm pregnancies. Hyperbilirubinemia and hypocalcemia (Choice D) are more likely to occur after birth and are not directly related to being postterm.
A nurse is talking to the parents of a 3-year-old child about water safety precautions. Which of the following statements made by the parents indicates a need for clarification?
- A. We keep the toilet seat down at all times.
- B. We don't answer the phone during bath time.
- C. We empty all buckets filled with water.
- D. We have our child in swimming lessons.
Correct Answer: D
Rationale: The correct answer is D because enrolling a 3-year-old child in swimming lessons does not necessarily prevent drowning incidents. It is crucial for parents to understand that even with swimming lessons, active supervision around water is essential to prevent accidents. Keeping the toilet seat down (A), avoiding distractions during bath time (B), and emptying buckets filled with water (C) are all important water safety precautions to prevent drowning incidents. Swimming lessons are beneficial, but they should not replace vigilant supervision.
At 10 weeks gestation, a primigravida asks the nurse what is occurring developmentally with her baby. Which response by the nurse is correct?
- A. The skin is wrinkled and fat is being formed.
- B. The eyelids are open and he can see.
- C. The kidneys are making urine.
- D. The heart is being developed.
Correct Answer: C
Rationale: Correct Answer: C - The kidneys are making urine.
Rationale: At 10 weeks gestation, the kidneys of the developing fetus begin to form and function, producing urine. This is a crucial milestone in fetal development as it indicates proper organ formation and functionality. The formation of urine by the kidneys plays a significant role in maintaining the amniotic fluid levels and supporting overall fetal growth and development.
Summary of other choices:
A: The skin is wrinkled and fat is being formed - Incorrect. Skin and fat formation typically occur later in gestation, not at 10 weeks.
B: The eyelids are open and he can see - Incorrect. Eye development is still in progress at 10 weeks, and the eyelids remain fused.
D: The heart is being developed - Incorrect. While the heart is forming at 10 weeks, it is not the most accurate response to the question posed by the primigravida.
A nurse is initiating a plan of care for a toddler who is hospitalized. Which of the following instructions is important to communicate to the nursing assistant?
- A. Have the toddler dress himself.
- B. Offer the toddler finger foods for snacks.
- C. Provide opportunities to share toys with others.
- D. Ask the child simple yes or no questions.
Correct Answer: B
Rationale: The correct answer is B: Offer the toddler finger foods for snacks. This instruction is important to communicate to the nursing assistant because toddlers are at risk for choking on certain foods due to their developing chewing and swallowing abilities. Finger foods are safer for toddlers to eat as they are easier to manage and reduce the risk of choking.
Other choices are incorrect because:
A: Having the toddler dress himself may not be appropriate as toddlers may need assistance and supervision due to their limited motor skills.
C: Providing opportunities to share toys with others is important for social development but is not as critical as ensuring the toddler's safety during meal times.
D: Asking the child simple yes or no questions is a good communication strategy but not as essential for the toddler's safety during snack times.