Nokea
A nurse in a provider's office is collecting data from a client who is at 34 weeks of gestation and reports having a sudden gush of vaginal fluid.
Which of the following manifestations is the priority?
- A. Maternal temperature 36.3°C (101)
- B. Amniotic fluid with meconium noted
- C. Fetal heart tones 98/min
- D. Foul smelling vaginal discharge
Correct Answer: C
Rationale: In this scenario, the priority is to assess the well-being of the fetus. Fetal heart tones provide critical information about fetal status, indicating whether the baby is experiencing any distress or compromise. A fetal heart rate of 98 beats per minute (bpm) is below the normal range (110-160 bpm), suggesting potential fetal distress that requires immediate attention.
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A nurse is reinforcing teaching about breastfeeding with a client who is postpartum.
Which of the following statements by the client indicates an understanding of the teaching?
- A. I will nurse my baby for 5 to 10 minutes on each breast.
- B. I will make sure that just the nipple is in my baby's mouth.
- C. I will apply vitamin E oil to my nipples after each feeding.
- D. I will lay my baby on a pillow at the level of my breast.
Correct Answer: D
Rationale: Using a pillow to support the baby at breast level ensures proper positioning and latch, making breastfeeding more comfortable and effective, indicating understanding of the teaching.
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. You will need to receive a medroxyprogesterone acetate injection once per month.
- B. Combined estrogen-progestin contraceptive pills cause longer periods.
- C. Oral contraceptives decrease the risk for endometrial cancer.
- D. You will need to have your diaphragm replaced every 4 years.
Correct Answer: C
Rationale: Oral contraceptives, particularly combined ones, decrease endometrial cancer risk, an important benefit to include in teaching about contraception.
A nurse is transporting a newborn to their parents from the nursery. Which of the following actions should the nurse perform to confirm the newborn's identity?
- A. Ask a parent to state the newborn's date of birth.
- B. Check the newborn's footprint sheet with the medical record.
- C. Request a parent to verify the newborn's name.
- D. Compare numbers on the newborn's band to the parent's band.
Correct Answer: D
Rationale: Comparing the identification numbers on the newborn's band with the parent's band is the most reliable method to confirm identity, ensuring the newborn is matched with the correct parent(s) and preventing mix-ups or abduction.
A nurse is collecting data from a client who has hyperemesis gravidarum.
Which of the following findings should the nurse anticipate?
- A. Increased fundal height
- B. Poor skin turgor
- C. Decreased pulse rate
- D. Proteinuria
Correct Answer: B
Rationale: Poor skin turgor is a common finding in clients with hyperemesis gravidarum due to dehydration. Excessive vomiting leads to fluid loss and dehydration, resulting in poor skin elasticity and turgor.
A home health nurse is caring for a client who has unilateral mastitis and is experiencing discomfort in the affected breast.
Which of the following instructions should the nurse include?
- A. Tell the client to apply hydrocortisone ointment to the affected area of the breast.
- B. Suggest the client apply warm compresses to the affected breast
- C. Recommend the client avoid wearing a nursing bra until symptoms resolve
- D. Encourage the client to limit oral fluid intake to decrease milk production
Correct Answer: B
Rationale: Applying warm compresses to the affected breast can help relieve pain and promote milk flow, which can aid in resolving the infection. Warmth can help reduce inflammation and make breastfeeding or pumping less painful.