Nokea
Which of the following is a potential complication of gestational hypertension?
- A. Preterm labor
- B. Fetal growth restriction
- C. Placental abruption
- D. All of the above
Correct Answer: D
Rationale: Gestational hypertension can lead to preterm labor, fetal growth restriction, and placental abruption.
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A nurse is admitting a client who is 1 week postpartum and reports excessive vaginal bleeding. The nurse speaks a different language than the client. The client's partner and 10-year-old child are accompanying her. Which of the following actions should the nurse take to gather the client's admission data?
- A. Have the client's child translate.
- B. Ask a nursing student who speaks the same language as the client to translate.
- C. Request a female interpreter through the facility
- D. Allow the client's partner to translate.
Correct Answer: C
Rationale: Requesting a female interpreter through the facility ensures accurate and professional communication, respecting the client's privacy and cultural preferences. Using a child or partner to translate is inappropriate and may lead to misunderstandings.
A nurse is assessing a newborn following a circumcision. Which of the following findings should the nurse identify as an indication that the newborn is experiencing pain?
- A. Decreased heart rate.
- B. Chin quivering.
- C. Pinpoint pupils.
- D. Slowed respirations.
Correct Answer: B
Rationale: Chin quivering is a sign of pain in newborns and should be addressed with appropriate pain management interventions.
A nurse is assessing a client who is postpartum following a cesarean birth. The client states, 'I feel like I have to urinate but I can’t go.' Which of the following actions should the nurse take?
- A. Assist the client to ambulate to the bathroom
- B. Insert an indwelling urinary catheter
- C. Perform a bladder scan to assess for urinary retention
- D. Administer a diuretic
Correct Answer: A
Rationale: The correct answer is A: Assist the client to ambulate to the bathroom. This action helps in promoting normal voiding patterns post-cesarean birth. Ambulation can aid in relieving pressure on the bladder, stimulating the urge to urinate, and facilitating the flow of urine. It also promotes circulation, which can help in reducing the risk of urinary retention.
Choice B: Inserting an indwelling urinary catheter should not be the initial intervention as it carries a risk of introducing infection and may not be necessary at this point.
Choice C: Performing a bladder scan can be considered if the client is unable to void after ambulation and other interventions have been attempted.
Choice D: Administering a diuretic is not appropriate in this situation as the client is experiencing difficulty in urinating rather than retaining excessive urine.
In summary, assisting the client to ambulate to the bathroom is the most appropriate initial action to address the client's complaint and promote normal voiding.
A nurse is caring for a client immediately following the delivery of a stillborn fetus. Which of the following actions should the nurse take?
- A. Limit the amount of time the fetus is in the client’s room.
- B. Provide the client with photos of the fetus.
- C. Instruct the client that an autopsy should be performed within 24 hr.
- D. Inform the client that the law requires them to name the fetus.
Correct Answer: B
Rationale: The correct answer is B: Provide the client with photos of the fetus. This action allows the client to have tangible memories of their stillborn baby, aiding in the grieving process and facilitating closure. It is important for the client to have something to remember their child by, as it validates the existence of the baby and acknowledges the client's loss. It also promotes a sense of connection and remembrance. Providing photos can be a compassionate gesture that supports the client emotionally during this difficult time.
Choice A is incorrect because limiting the time the fetus is in the room may not consider the client's emotional needs. Choice C is incorrect as it may add unnecessary stress to the client. Choice D is incorrect as there is no legal requirement to name a stillborn fetus.
A nurse is caring for a client who is at 36 weeks of gestation and has methicillin-resistant Staphylococcus aureus. Which of the following types of isolation precautions should the nurse initiate?
- A. Droplet
- B. Contact
- C. Protective environment
- D. Airborne
Correct Answer: B
Rationale: The correct answer is B: Contact precautions. Methicillin-resistant Staphylococcus aureus (MRSA) is primarily spread through direct contact with infected individuals or contaminated surfaces. Therefore, the nurse should initiate contact precautions to prevent the spread of MRSA to others. Droplet precautions (choice A) are used for diseases transmitted via respiratory droplets, such as influenza. Protective environment (choice C) is used for immunocompromised clients to protect them from environmental pathogens. Airborne precautions (choice D) are for diseases transmitted via small droplet nuclei, like tuberculosis. No other choices are applicable for MRSA.