Nokea
With a breech presentation, the nurse must be particularly alert for which of the following?
- A. quickening
- B. ophthalmia neonatorum
- C. pica
- D. prolapsed umbilical cord
Correct Answer: D
Rationale: Prolapsed umbilical cord is the descent of the umbilical cord into the vagina before the fetal presenting part and compression of the cord between the presenting part and the maternal pelvis, compromising or completely cutting off fetoplacental perfusion. This is an emergency situation; immediate delivery should be attempted to save the fetus.
You may also like to solve these questions
A woman asks, 'How much alcohol can I safely drink while pregnant?' The nurse's best response is:
- A. The amount of alcohol that is safe during pregnancy is unknown.'
- B. Consuming one or two beers or glasses of wine a day is considered safe for a healthy pregnant woman.'
- C. Drinking three or more drinks on any given occasion is the only harmful type of drinking during pregnancy.'
- D. You can have a drink to help you relax and get to sleep at night.'
Correct Answer: A
Rationale: The amount of alcohol that is safe during pregnancy is unknown. Fetal alcohol syndrome is a combination of mental and physical abnormalities present in infants born to mothers who have consumed alcohol during pregnancy.
A client with a diagnosis of Schizophrenia has been released from an acute care setting. The client had a prolonged recovery from relapse. One of the parents says to the discharge nurse, 'I do not understand what is going on. The hospital said she was better, but all she does is sit around all day and smoke. We cannot get her to go to the vocational training you arranged.' The nurse recognizes that more teaching is needed about:
- A. the pathophysiology and acting out behaviors of schizophrenia.
- B. support groups that can help the parents release their feelings of frustration.
- C. the prolonged recovery time and depressive effects of medicines to prevent relapse.
- D. motivational techniques that are effective in clients with schizophrenia.
Correct Answer: C
Rationale: The nurse conducting discharge teaching must stress the lengthy recuperation process with emphasis on the sedative qualities of the medication used to prevent relapse. Support groups are useful for caregivers. The emphasis during recuperation is on maintaining nutrition and hygiene.
The nurse observes bilateral bruises on the arms of an elderly client in a long-term care facility. Which of the following questions should the nurse ask this client?
- A. How did you get those bruises?'
- B. Did someone grab you by your arms?'
- C. Do you fall often?'
- D. What did you bump against?'
Correct Answer: B
Rationale: Using a direct approach is best when asking about suspected abuse. Clients are reluctant to report abuse because of shame and fear of reprisal.
Neural tube defects in the fetus have been primarily associated with which deficiency in the mother?
- A. iron
- B. folic acid
- C. vitamin B12
- D. vitamin E
Correct Answer: B
Rationale: Folic acid is essential for the development of the neural tube and might prevent the defect or failure of the tube to close (congenital anomalies).
A 60-year-old widower is hospitalized after complaining of difficulty sleeping, extreme apprehension, shortness of breath, and a sense of impending doom. What is the best response by the nurse?
- A. You have nothing to worry about. You are in a safe place. Try to relax.'
- B. Has anything happened recently or in the past that might have triggered these feelings?'
- C. We have given you a medication that helps to decrease feelings of anxiety.'
- D. Take some deep breaths and try to calm down.'
Correct Answer: B
Rationale: Choice 2 provides support, reassurance, and an opportunity to gain insight into the cause of the anxiety. Choice 1 dismisses the client's feelings and offers false reassurance. Choices 3 and 4 do not allow the client to discuss his feelings, which he must do in order to understand and resolve the cause of his anxiety.