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A nurse is collecting data from a client who is at 28 weeks of gestation.
Which of the following findings is the nurse's priority?
- A. FHR 160/min
- B. Fundal height 24 cm
- C. Blood pressure 136/84 mm Hg
- D. Trace protein on urine reagent strip
Correct Answer: B
Rationale: A fundal height of 24 cm at 28 weeks is lower than expected, suggesting intrauterine growth restriction, requiring further evaluation.
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A nurse is reinforcing teaching with a client about various contraceptive methods.
Which of the following statements should the nurse include in the teaching?
- A. Combined estrogen-progestin contraceptive pills cause longer periods.
- B. You will need to have your diaphragm replaced every 4 years.
- C. Oral contraceptives decrease the risk for endometrial cancer.
- D. You will need to receive a medroxyprogesterone acetate injection once per month.
Correct Answer: C
Rationale: Combined oral contraceptives reduce the risk of endometrial cancer by suppressing ovulation and stabilizing hormone levels, preventing endometrial proliferation.
A nurse is assisting with the care of a newborn who has neonatal abstinence syndrome.
Which of the following actions should the nurse take first?
- A. Swaddle the newborn in blankets
- B. Determine the newborn's respiratory rate
- C. Auscultate the newborn's bowel sounds.
- D. Weigh the newborn's wet diaper
Correct Answer: B
Rationale: Determining respiratory rate is the priority to assess for distress, as neonatal abstinence syndrome can cause tachypnea.
A nurse is reinforcing discharge instructions about breastfeeding with a client.
Which of the following statements should the nurse make?
- A. You should feed your baby six times a day.
- B. You should wake your baby at least every 6 hours at night for feedings.
- C. You should recognize that your baby sucking on his hands is a hunger cue.
- D. You should feed your baby for 10 minutes on each breast.
Correct Answer: C
Rationale: Sucking on hands is an early hunger cue, aiding effective feeding by recognizing the baby's needs.
A nurse is reinforcing teaching about preterm labor with a client who is at 28 weeks of gestation.
Which of the following statements by the client indicates an understanding of the teaching?
- A. I should expect to feel pain in my upper right abdomen if I'm having preterm labor.
- B. If I have contractions more often than every 10 minutes, I might be in preterm labor.
- C. I might be experiencing preterm labor if walking stops my contractions.
- D. I can take a daily iron supplement to prevent preterm labor.
Correct Answer: B
Rationale: Frequent contractions (more than every 10 minutes) indicate possible preterm labor, requiring medical evaluation.
A nurse is collecting data from a client who has hyperemesis gravidarum.
Which of the following findings should the nurse anticipate?
- A. Poor skin turgor
- B. Decreased pulse rate
- C. Increased fundal height
- D. Proteinuria
Correct Answer: A
Rationale: Poor skin turgor indicates dehydration, a common consequence of severe vomiting in hyperemesis gravidarum.