The client at 18 weeks' gestation thinks she might have been exposed to a toxin at work that could affect fetal development. The client asks the nurse what organs might be affected at this point in pregnancy. The best response of the nurse is:
1. "The brain is developing now, and could be affected."
2. "Because you are in the second trimester, there is no danger."
3. "The internal organs like the heart and lungs could be impacted."
4. "It's best to not worry about possible problems with your baby."
1
Rationale:
1. Maximum brain growth and myelination are occurring at this point in fetal development.
2. Although the greatest danger from teratogens is during the embryonic stage (the first 8 weeks of pregnancy), the fetus at 20 weeks is still vulnerable to exposure to teratogens.
3. The heart, lungs, and other internal organs form during the embryonic state, or the first 8 weeks of pregnancy. During their formation is when they are most likely to be affected by a teratogen.
4. Avoid telling clients to not worry. Doing so indicates to the client that you don't care about their concerns, and will end effective communication.
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After teaching a client with early polycystic kidney disease (PKD) about nutritional therapy, the nurse assesses the client's understanding. Which statement made by the client indicates a correct understanding of the teaching?
a. "I will take a laxative every night before going to bed." b. "I must increase my intake of dietary fiber and fluids." c. "I shall only use salt when I am cooking my own food." d. "I'll eat white bread to minimize gastrointestinal gas."
A nurse is assessing a patient for Chadwick's sign. In order to do this correctly, what action does the nurse take?
A. Assesses the color of the patient's vaginal mucosa and cervix. B. Feels the patient's abdomen for passive fetal movement. C. Obtains a urine specimen for a pregnancy test. D. Palpates the patient's abdomen for uterine asymmetry.
It is important for the clinician to recognize that a recurrence of depression is:
A. 50% likely after one episode B. 70% likely after two episodes C. 90% likely after three episodes D. All of the above
To treat a dysrhythmia, atropine sulfate has been administered intravenously. The nurse would monitor for:
1. weight gain. 2. tachycardia. 3. muscle twitching. 4. incontinence of urine.