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A nurse in a provider's office is reinforcing teaching with a client who is pregnant and is scheduled for a nonstress test.
Which of the following statements should the nurse make?
- A. You will not be able to eat or drink anything for 8 hours prior to the test.
- B. You will receive medication through an IV line to stimulate contractions.
- C. You will press the provided button when you feel the baby moving during the test.
- D. You will be required to lie flat on your back for the duration of the test.
Correct Answer: C
Rationale: During a nonstress test, the client presses a button when they feel fetal movement to monitor fetal heart rate response, assessing fetal well-being. No fasting, IV medication, or lying flat is required.
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A nurse is reinforcing teaching with a client about common discomforts during the first trimester of pregnancy.
Which of the following discomforts should the nurse include in the teaching?
- A. Round ligament pain
- B. Perineal discomfort and pressure
- C. Tingling in the fingers
- D. Urination urgency and frequency
Correct Answer: D
Rationale: Increased urinary urgency and frequency are common in the first trimester due to hormonal changes and uterine pressure on the bladder.
A nurse is contributing to the plan of care for a client who is postpartum and has mastitis.
Which of the following actions should the nurse plan to take?
- A. Limit the client's daily fluid intake
- B. Encourage the client to wear a bra that is loose fitting
- C. Encourage the client to continue to breastfeed.
- D. Prepare the client for an abdominal sonogram
Correct Answer: C
Rationale: Continued breastfeeding prevents milk stasis and reduces the risk of abscess formation in mastitis.
A nurse is caring for a 2-day-old newborn who is undergoing phototherapy for treatment of hyperbilirubinemia.
Which of the following actions should the nurse take?
- A. Provide additional hydration by offering glucose water.
- B. Apply a water-based lotion to the newborn's skin every 4 hr.
- C. Monitor the newborn's heart rate every 2 hr.
- D. Remove the newborn from phototherapy every 2 hr for breastfeeding
Correct Answer: D
Rationale: Frequent breastfeeding enhances bilirubin excretion through stooling and supports hydration during phototherapy.
A nurse in an antepartum unit is assisting with the care of a client who has preeclampsia and is receiving IV magnesium sulfate therapy.
For which of the following adverse effects should the nurse monitor and report to the provider?
- A. Polyuria
- B. Hyporeflexia
- C. Agitation
- D. Tachypnea
Correct Answer: B
Rationale: Hyporeflexia is an early sign of magnesium toxicity, indicating excessive neuromuscular blockade, requiring immediate reporting.
A nurse is collecting data from a client who is at 26 weeks of gestation and whose last appointment was 1 month ago.
Which of the following findings should the nurse report to the provider?
- A. Double vision
- B. Pedal edema
- C. Weight gain of 1 kg (2.2lb)
- D. BP of 132/84mm Hg
Correct Answer: A
Rationale: Double vision suggests severe preeclampsia, requiring immediate evaluation to prevent complications like eclampsia.