The nurse is interviewing a primigravida client who is 17 weeks pregnant. During the data collection the client reports she has not felt the baby move yet. The most appropriate response by the nurse would be:
1. "We will listen for the heartbeat today.".
2. "You need an ultrasound.".
3. "Fetal movement does not occur until the 18th week.".
4. "Do you have reason to believe your baby is not ok?"
3
Rationale 1: While all prenatal care appointments at this gestational age and beyond will include an assessment of the fetal heartbeat, this option does not meet the client's need for education.
Rationale 2: Ultrasounds may be performed to assess for fetal viability but there is no indication at this time the pregnancy is at risk.
Rationale 3: Quickening, the fluttery initial sensations of fetal movement perceived by the mother, usually occurs at approximately 18 weeks, possibly earlier in women who have given birth before. This mother is in need of factual information from the nurse.
Rationale 4: Asking if the client is feeling uneasy about the health of the pregnancy does not meet the client's need for information.
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The nurse is caring for a patient with impaired diffusion of oxygen secondary to pneumonia. Assessment findings related to this impairment are similar to those the nurse would see in patients with which other disease states?
1. Spinal cord injuries 2. Flail chest 3. Atelectasis 4. Carbon monoxide poisoning
In caring for a client on lithium therapy, the nurse should:
a. encourage the client to avoid sodium-based beverages. b. instruct the client to consume foods low in sodium. c. assess the client for use of diuretics. d. instruct significant others to monitor client's vital signs daily at home.
The nurse anticipates the client's laboratory values will result in increased ______ due to treatment with Kaletra?
a. cholesterol b. magnesium c. potassium d. calcium
To increase the effectiveness of a 5-HT3 receptor antagonist, the nurse may also administer:
1. dexamethasone. 2. ranitidine. 3. loperamide. 4. hyoscyamine.