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. Which response by the nurse is the most appropriate?
1. "We will listen for the heartbeat today."
2. "You need an ultrasound."
3. "Fetal movement may not be felt until the 18th week."
4. "Do you have reason to believe your baby is not ok?"
Correct Answer: 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. While all prenatal care appointments at this gestation and beyond will include an assessment of the fetal heartbeat, this option does not meet the client's need for education. Ultrasounds may be performed to assess for fetal viability but there is no indication at this time the pregnancy is at risk. 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 older adult patient with osteoporosis is at risk for falls. To maintain safety in the home, the nurse would advise the patient to:
1. take the rubber mat out of the shower. 2. install a grab rail in the bath, shower, and by the toilet. 3. avoid rubber-soled shoes. 4. avoid exercise.
A client with prostate cancer calls the clinic to ask for a physical therapy (PT) consult because his back has been hurting. Which action by the nurse is most appropriate?
a. Advise the client to try a heating pad for 3 days before initiating a PT consult. b. Call in a prescription for nonsteroidal anti-inflammatory medications. c. Collaborate with the physician to arrange the physical therapy consult. d. Instruct the client to come in for a back x-ray immediately.
Following an arthrocentesis of the right knee in the physician's office, the nurse gives the following instructions to the client:
A) Apply warm moist heat as needed for pain relief. B) Remove the pressure dressing when you get home. C) Limit use of the joint for 2 to 3 days. D) Begin range-of-motion exercises to the knee in 24 hours.
Which teaching point should the nurse plan to include when caring for a patient whose vision is corrected to 20/200?
a. How to access audio books b. How to use a white cane safely c. Where Braille instruction is available d. Where to obtain specialized magnifiers