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Which of the following findings should the nurse report to the provider? Select all that apply
- A. Abdominal assessment.
- B. Vaginal Discharge.
- C. Heart rate.
- D. Temperature.
- E. Dyspareunia.
- F. Condom usage.
Correct Answer: B, E
Rationale:
The nurse should report vaginal discharge (B) as it could indicate infection or other issues. Dyspareunia (E) should also be reported as it can indicate underlying problems. Abdominal assessment (A) may be part of routine care but doesn't necessarily require immediate reporting. Heart rate (C) and temperature (D) are vital signs that should be monitored but don't specifically indicate a need for immediate reporting. Condom usage (F) is important for sexual health discussions but does not require reporting to the provider.
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A nurse is teaching a client who has pregestational type 1 diabetes mellitus about management during pregnancy. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will need to increase my insulin doses during the first trimester.
- B. I should engage in moderate exercise for 30 minutes if my blood glucose is 250 or greater.
- C. I will continue taking my insulin if I experience nausea and vomiting.
- D. I will ensure that my bedtime snack is high in refined sugar.
Correct Answer: C
Rationale: Correct Answer: C
Rationale: The correct answer is C because continuing to take insulin even when experiencing nausea and vomiting is crucial for managing blood glucose levels in pregestational type 1 diabetes during pregnancy. Nausea and vomiting can lead to decreased food intake, which may result in hypoglycemia if insulin doses are not adjusted accordingly. It is important for the client to maintain stable blood glucose levels for optimal fetal health.
Summary of Incorrect Choices:
A: Increasing insulin doses during the first trimester may not be necessary and should be done under the guidance of a healthcare provider.
B: Exercising with blood glucose levels of 250 or greater is not safe and can lead to further hyperglycemia.
D: Consuming a bedtime snack high in refined sugar can cause blood glucose spikes and should be avoided in diabetes management.
A nurse who is caring for a client who is at 15 weeks of gestation, is Rh-negative, and has just had an amniocentesis. Which of the following interventions is the nurse's priority following the procedure?
- A. Check the client's temperature.
- B. Observe for uterine contractions.
- C. Administer Rh(0) Immune globulin.
- D. Monitor the FHR.
Correct Answer: C
Rationale: The correct answer is C: Administer Rh(0) Immune globulin. This is the priority intervention as the client is Rh-negative and has just undergone an invasive procedure like amniocentesis, which carries a risk of fetal-maternal blood transfer. Administering Rh(0) Immune globulin helps prevent the development of Rh incompatibility, which could lead to hemolytic disease in the newborn. Checking the client's temperature (A) and monitoring the FHR (D) are important but not the priority immediately post-procedure. Observing for uterine contractions (B) is important but not the priority for an Rh-negative client after amniocentesis.
A school nurse is providing teaching to an adolescent about levonorgestrel contraception. Which of the following information should the nurse include in the teaching?
- A. You should take the medication within 72 hours following unprotected sexual intercourse.
- B. You should avoid taking this medication if you are on an oral contraceptive.
- C. If you don't start your period within 5 days of taking this medication, you will need a pregnancy test.
- D. One dose of this medication will prevent you from becoming pregnant for 14 days after taking it.
Correct Answer: A
Rationale: The correct answer is A: You should take the medication within 72 hours following unprotected sexual intercourse. Levonorgestrel is most effective when taken within 72 hours after unprotected sex to prevent pregnancy. This timing is crucial for its efficacy.
Choice B is incorrect because levonorgestrel can be used in combination with oral contraceptives if needed. Choice C is incorrect as the absence of a period does not always indicate pregnancy, and a pregnancy test may not be necessary. Choice D is incorrect because levonorgestrel is effective for a shorter duration, not 14 days.
A nurse is planning care for a client who is to undergo a nonstress test. Which of the following actions should the nurse include in the plan of care?
- A. Maintain the client NPO throughout the procedure.
- B. Place the client in a supine position.
- C. Instruct the client to massage the abdomen to stimulate fetal movement.
- D. Instruct the client to press the provided button each time fetal movement is detected.
Correct Answer: D
Rationale: The correct answer is D: Instruct the client to press the provided button each time fetal movement is detected. This action is essential during a nonstress test to track fetal movement and heart rate patterns. By pressing the button each time fetal movement is felt, the nurse can correlate these movements with any changes in the fetal heart rate, providing valuable information about fetal well-being. Maintaining the client NPO (A) is not necessary for a nonstress test. Placing the client in a supine position (B) can reduce blood flow to the fetus and is not recommended. Instructing the client to massage the abdomen (C) may lead to inaccurate test results by artificially stimulating fetal movements.
A nurse is teaching a client who is at 10 weeks of gestation about nutrition during pregnancy. Which of the following statements by the client indicates an understanding of the teaching?
- A. I should increase my protein intake to 60 grams each day.
- B. I should drink 2 liters of water each day.
- C. I should increase my overall daily caloric intake by 300 calories.
- D. I should take 600 micrograms of folic acid each day.
Correct Answer: D
Rationale: The correct answer is D because folic acid is crucial during pregnancy to prevent birth defects like spina bifida. It is recommended to take 600 micrograms daily. Choice A is incorrect as the recommended protein intake is 71 grams/day. Choice B is important but doesn't address nutrition specifically. Choice C is unnecessary and could lead to excessive weight gain.