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A patient who uses a diaphragm as contraception asks if they need to use a backup method. What should the nurse respond?
- A. No, the diaphragm is effective on its own and does not require a backup method.
- B. Yes, a diaphragm is effective only when used with spermicide, so a backup method is advised.
- C. Yes, a diaphragm should always be used with a condom for additional protection.
- D. No, but the diaphragm should be replaced every 6 months.
Correct Answer: B
Rationale: The diaphragm should be used with spermicide for maximum effectiveness. Choice A is incorrect because while the diaphragm is effective, spermicide enhances its performance and ensures greater protection. Choice C is unnecessary, as the diaphragm alone with spermicide is sufficient. Choice D is incorrect because while regular replacement is recommended, it does not require a backup method.
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A client at 36 weeks' gestation reports decreased fetal movement. What is the nurse's priority action?
- A. Perform a nonstress test.
- B. Encourage the client to drink orange juice.
- C. Schedule an ultrasound.
- D. Notify the healthcare provider.
Correct Answer: A
Rationale: A nonstress test evaluates fetal well-being and is the first step in assessing decreased fetal movement.
The nurse is monitoring a client who is 34 weeks ges- dividing?
- A. Trophoblast or inner cell mass that becomes the fetal monitor tracing are a priority for the nurse to placenta
- B. Embryoblast or inner cell mass that becomes the that apply. embryo
- C. Baseline FHR 140, accelerations, late decelerations,
- D. Morula
Correct Answer: A
Rationale: In the context of the question, the nurse is monitoring a 34-week gestation client. At 34 weeks, the trophoblast or inner cell mass has already developed into the placenta, which is formed earlier in pregnancy. Therefore, choice A is the most relevant option in this scenario. Trophoblast is critical for implantation and the formation of the placenta, which plays a vital role in supporting the developing fetus by providing oxygen and nutrients. Understanding the different stages of fetal development can help the nurse provide optimal care and monitor for any potential issues that may arise during pregnancy.
On admission to the nursery, a newborn is observed to be experiencing cold stress. The basis for the nursing intervention at this time would be to minimize:
- A. Shivering
- B. Hyperglycemia
- C. Oxygen consumption
- D. Metabolism of fat stores
Correct Answer: C
Rationale: Cold stress in a newborn can lead to an increase in oxygen consumption as the body works harder to maintain a normal body temperature. By minimizing oxygen consumption, the nursing intervention aims to prevent excessive oxygen demand and help the newborn cope with the cold stress more effectively. This can be achieved through methods such as swaddling, warming equipment, and ensuring the baby's environment is appropriately heated to maintain a stable body temperature. Minimizing oxygen consumption can help conserve energy and promote overall well-being in the newborn.
A pregnant client asks about the purpose of taking folic acid. What is the nurse's best response?
- A. It prevents gestational diabetes.
- B. It helps prevent neural tube defects.
- C. It supports fetal bone development.
- D. It reduces the risk of preterm labor.
Correct Answer: B
Rationale: Folic acid is essential for preventing neural tube defects like spina bifida during early fetal development.
A nurse is assessing a newborn who is 48 hours old and has a maternal history of methadone use during pregnancy. Which of the following manifestations should the nurse identify as an indication of neonatal abstinence syndrome?
- A. Hyporeactivity
- B. Excessive high-pitched cry
- C. Acrocyanosis
- D. Respiratory rate of 50/min
Correct Answer: B
Rationale: Neonatal abstinence syndrome (NAS) occurs in newborns who were exposed to substances, such as methadone, while in the womb. Infants with NAS may exhibit excessive high-pitched crying as one of the manifestations. Other common symptoms of NAS include irritability, tremors, feeding difficulties, sweating, fever, vomiting, diarrhea, and poor weight gain. Therefore, in this case, the excessive high-pitched cry is a manifestation that the nurse should identify as an indication of neonatal abstinence syndrome.