Scenario:

A nurse is caring for a 26-year-old gravida 2 para 1 female client in the labor and delivery unit. The client previously delivered vaginally three years ago under epidural anesthesia. Her current pregnancy has progressed normally with a weight gain of 28 lbs (12.7 kg) and no reported blood pressure issues. Group B Streptococcus screening is negative, and all pregnancy-related laboratory results, including rubella immunity, are within normal limits. The client has a blood type of O, Rh-positive.

Exhibits

The nurse teaches the client about the fetus's reaction to labor by:

Select the most appropriate options missing from the statements below. Describing heart rate patterns by
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Evaluating the relationship when a contraction occurs by
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Answer and Explanation

The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"A"}

Complete the sentence: The nurse teaches the client about the fetus's reaction to labor by explaining that early decelerations indicate head compression and assessing fetal heart rate patterns before, during, and after contractions.

Rationale for correct answer: Explaining that early decelerations indicate head compression is correct because early decelerations are typically associated with head compression during contractions. This is a common finding during labor and usually not a sign of fetal distress. It indicates that the fetus is descending through the birth canal, causing temporary compression of the fetal head, which leads to a brief decrease in heart rate.

Assessing fetal heart rate patterns before, during, and after contractions is correct because it provides a comprehensive understanding of how the fetus responds to labor. Monitoring the fetal heart rate throughout the contraction cycle helps identify patterns of variability, decelerations, and accelerations, ensuring that the fetus is tolerating labor well.

Rationale for incorrect answers: Choice A rationale: Identifying early decelerations as a sign of fetal distress is incorrect because early decelerations are generally benign and related to head compression. They are not typically a sign of fetal distress. Late or variable decelerations are more concerning and may indicate fetal distress.

Choice C rationale: Stating that early decelerations require immediate intervention is incorrect because early decelerations do not usually require immediate intervention. They are a normal finding during labor caused by head compression. Interventions are necessary for late or variable decelerations, which indicate possible fetal compromise.

Choice D rationale: Noting that early decelerations suggest umbilical cord compression is incorrect because early decelerations are not typically associated with umbilical cord compression. Variable decelerations are more likely to indicate cord compression, requiring closer monitoring and possible intervention.

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Correct Answer is A

Explanation

Choice A rationale

Reporting the client's jaw pain to the healthcare provider is crucial because jaw pain is a potential symptom of osteonecrosis of the jaw (ONJ), a rare but serious side effect of bisphosphonates like alendronate. ONJ involves the death of bone tissue in the jaw, leading to significant complications. Early intervention and management are essential to prevent further deterioration and address any underlying issues.

Choice B rationale

Determining how the client is administering the medication is important but not the immediate priority when addressing jaw pain, which could indicate a serious complication. Ensuring proper administration can prevent future issues but does not address the immediate concern of potential ONJ.

Choice C rationale

Advising the client to gargle with warm salt water twice daily may provide temporary relief from minor oral discomfort but is not appropriate for addressing potential osteonecrosis of the jaw. This suggestion does not address the underlying cause of jaw pain in a client taking bisphosphonates.

Choice D rationale

Confirming that jaw pain is a common symptom of osteoporosis is incorrect. While musculoskeletal pain can be associated with osteoporosis, jaw pain in a client taking alendronate may indicate osteonecrosis of the jaw, a serious condition requiring prompt medical attention.

A. Participation of community leaders in planning the program. B. Morbidity data for breast cancer in women of all races. C. A listing of African-American women who live in the community. D. Technical assistance to produce a video on breast self-examination.

Correct Answer is A

Explanation

Choice A rationale

Participation of community leaders in planning the program is crucial because these leaders have an in-depth understanding of the community's needs and concerns. Their involvement ensures that the program is culturally relevant and addresses the specific health disparities faced by African-American women. Additionally, community leaders can help foster trust and encourage participation from community members, making the program more effective.

Choice B rationale

While morbidity data for breast cancer in women of all races can provide valuable information on overall trends, it does not address the specific needs and challenges faced by African-American women. Focusing on the unique risks and barriers faced by this group is essential for designing an effective health promotion program.

Choice C rationale

A listing of African-American women who live in the community is useful for outreach and engagement but does not provide the essential insight needed to design a culturally sensitive and relevant program. Participation from community leaders is more effective in understanding and addressing the community's specific needs.

Choice D rationale

Technical assistance to produce a video on breast self-examination is valuable for education but is not the most important resource for designing a comprehensive health promotion program. The program must be tailored to the community's unique needs, which requires input from community leaders.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A female client is taking alendronate, a bisphosphonate, for postmenopausal osteoporosis. The client tells the nurse that she is experiencing jaw pain. How should the nurse respond?

Correct Answer is A

Explanation

The nurse has received funding to design a health promotion project for African-American women who are at risk for developing breast cancer. Which resource is most important in designing this program?

Correct Answer is A

Explanation

Exhibits The nurse is reviewing the client's data. Which of the following findings should the nurse report to the primary health care provider immediately? Select all that apply.

The friend of a nurse who works in an acute care hospital asks the nurse to review the adult daughter's electronic medical record (EMR) to determine if she is honestly disclosing her medical condition. The nurse's reply should include which information? Select all that apply.

A nurse is caring for a 59-year-old male client in the intermediate care unit. Exhibits Which of the following findings requires the nurse's immediate attention?

The nurse is preparing to obtain a rapid coronavirus (COVID-19) test for a client who was exposed to the virus eight days ago. The client is experiencing fever, cough, and shortness of breath. Which action is most important for the nurse to take?