Nokea
Client at 34 weeks of gestation, suspected placenta previa
Which of the following actions should the nurse take?
- A. Perform a rectal exam.
- B. Apply an external fetal monitor.
- C. Complete a vaginal exam.
- D. Apply ice to the perineal area.
Correct Answer: B
Rationale: The correct answer is B: Apply an external fetal monitor. This action is crucial in monitoring the fetal heart rate and uterine contractions during labor, ensuring the well-being of both the mother and the baby. Performing a rectal exam (choice A) is not indicated in this context. Completing a vaginal exam (choice C) may be necessary but is not the immediate priority. Applying ice to the perineal area (choice D) is not relevant for fetal monitoring. Other choices are not provided.
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Client in second trimester, new diagnosis of gestational diabetes
Which statement by the client indicates a need for further teaching?
- A. I should limit my carbohydrates to 50% of caloric intake.
- B. I will take my glyburide daily with breakfast.
- C. I will reduce my exercise schedule to 3 days a week.
- D. I know I am at increased risk to develop type 2 diabetes.
Correct Answer: C
Rationale: The correct answer is C because reducing the exercise schedule to 3 days a week contradicts the goal of managing type 2 diabetes through regular physical activity. Exercise helps control blood sugar levels and improves insulin sensitivity. Limiting exercise can lead to poor diabetes management. Choice A shows understanding of carbohydrate control. Choice B indicates adherence to medication regimen. Choice D demonstrates awareness of diabetes risk.
Client pregnant, taking iron supplements for iron-deficiency anemia, reports black stools, no abdominal pain or cramping
Which of the following responses by the nurse is appropriate?
- A. What else have you been eating?
- B. Go to the emergency room and your provider will meet you there.
- C. This is expected because of the way iron is broken down during digestion.
- D. Come to the office and we will check things out.
Correct Answer: C
Rationale: The correct answer is C because it provides an appropriate explanation for the situation. Iron is known to cause dark stools due to its breakdown in the digestive system. This response shows understanding and reassures the patient. Choice A is relevant but doesn't address the specific issue. Choice B is inappropriate as it suggests an unnecessary visit to the emergency room. Choice D is a general invitation without addressing the concern.
Client in second trimester, new diagnosis of gestational diabetes
Which statement by the client indicates a need for further teaching?
- A. I should limit my carbohydrates to 50% of caloric intake.
- B. I will take my glyburide daily with breakfast.
- C. I will reduce my exercise schedule to 3 days a week.
- D. I know I am at increased risk to develop type 2 diabetes.
Correct Answer: C
Rationale: The correct answer is C because reducing the exercise schedule to 3 days a week contradicts the importance of regular physical activity in managing diabetes. Regular exercise helps improve insulin sensitivity and control blood sugar levels. Limiting carbohydrates to 50% of caloric intake (choice A) is a recommended dietary guideline for diabetes management. Taking glyburide daily with breakfast (choice B) indicates adherence to medication therapy. Knowing about the increased risk of developing type 2 diabetes (choice D) shows awareness of the condition.
Client immediate postoperative period, removal of ectopic pregnancy via salpingostomy
The nurse should prepare to administer Rho(D) immune globulin (RhoGAM or RhiG) as prescribed if the record indicates that the client
- A. has previously given birth to an Rh-negative infant.
- B. has had significant blood loss during the procedure.
- C. has expressed a desire to conceive again.
- D. is Rh-negative.
Correct Answer: D
Rationale: The correct answer is D because Rho(D) immune globulin is administered to Rh-negative mothers to prevent hemolytic disease of the newborn in future pregnancies with Rh-positive infants. Choice A is incorrect because having an Rh-negative infant does not warrant the administration of RhoGAM. Choice B is incorrect because significant blood loss does not relate to the need for RhoGAM. Choice C is incorrect as the desire to conceive again does not indicate the necessity for RhoGAM administration.
Postpartum client, large amount of lochia rubra with several clots on perineal pad
Which of the following actions should the nurse take first?
- A. Measure the client's vital signs.
- B. Check the client's fundus.
- C. Feel for a full bladder.
- D. Request the provider perform a vaginal examination.
Correct Answer: B
Rationale: The correct action the nurse should take first is to check the client's fundus. This is prioritized because assessing the fundus helps determine the status of postpartum uterine involution and can indicate any signs of hemorrhage. By checking the fundus first, the nurse can promptly identify and address any abnormalities or complications. Measuring vital signs and feeling for a full bladder are important assessments but come after checking the fundus. Requesting a provider perform a vaginal examination is not the first action to take unless there are specific concerns or indications for it.