A laboring client's membranes have just ruptured. What is the nurse's next action?

Correct Answer: A

Rationale: In this scenario, the correct next action for the nurse after a laboring client's membranes rupture is to assess the fetal heart rate pattern. This is because ruptured membranes can lead to potential fetal distress, so monitoring the fetal heart rate is crucial to ensure the well-being of the baby. Option B, monitoring uterine contractions, while important during labor, is not the priority in this immediate situation where fetal well-being needs to be assessed promptly. Option C, administering oxygen, may be needed later depending on the situation, but it is not the initial action to take after the membranes rupture. Option D, preparing for delivery, is premature as a response without first assessing the fetal heart rate to determine the urgency of the situation. In an educational context, this question highlights the importance of prioritizing actions in maternal newborn care. It emphasizes the need for nurses to promptly assess fetal well-being in response to significant events during labor to provide appropriate and timely interventions. Understanding the sequence of actions in obstetric emergencies is critical for providing safe and effective care to laboring clients and their babies.

Correct Answer: B

Rationale: In the first trimester of pregnancy, hormonal changes play a significant role in causing indigestion and heartburn. Progesterone, which is elevated during pregnancy, causes relaxation of the cardiac sphincter, the valve that separates the esophagus from the stomach. This relaxation allows stomach acid to reflux back into the esophagus, leading to symptoms of indigestion and heartburn. Option A is incorrect because estrogen, another hormone present in pregnancy, does not directly cause increased appetite. Option C is incorrect because although HCG hormone levels are elevated in early pregnancy, it does not lead to increased gastric acidity. Option D is incorrect because while the growing uterus can contribute to feelings of fullness and pressure in the stomach, it is not the primary cause of indigestion and heartburn in early pregnancy. Understanding the physiological changes that occur during pregnancy is crucial for nurses providing education to pregnant clients. By explaining the specific hormonal effects on the digestive system, nurses can empower clients to make informed lifestyle and dietary choices to manage symptoms effectively and promote overall maternal well-being.

Correct Answer: B

Rationale: In caring for a client experiencing urinary incontinence, recommending Kegel exercises (Option B) is crucial. Kegel exercises strengthen the pelvic floor muscles, which support the bladder and urethra, helping to improve bladder control and reduce incontinence episodes. This intervention is evidence-based and widely recommended in the management of urinary incontinence. Option A is incorrect as drinking large amounts of water before bedtime can actually worsen urinary incontinence by increasing the frequency of urination during the night. Option C is incorrect because fiber is important for maintaining bowel regularity and should not be limited to avoid bowel irritation. Option D is also incorrect because caffeinated and carbonated beverages can irritate the bladder, leading to increased urinary urgency and incontinence. In an educational context, it is essential for nurses to understand the underlying causes of urinary incontinence and the appropriate interventions to help clients manage this condition effectively. By teaching clients about Kegel exercises, nurses empower them to take an active role in improving their bladder control and quality of life.

Correct Answer: B

Rationale: In this scenario, the correct answer is B) Muscle and joint pain. Anastrozole, an aromatase inhibitor used in breast cancer treatment, can lead to musculoskeletal side effects such as muscle and joint pain. This occurs due to decreased estrogen levels in the body, impacting bone density and joint health. Option A) Weight gain is incorrect because anastrozole is not typically associated with weight gain. Option C) Night sweats are more commonly seen with hormonal changes like menopause, not specifically linked to anastrozole. Option D) Increased appetite is not a typical side effect of anastrozole. Educationally, it is essential for nurses to understand the side effects of medications used in breast cancer treatment to provide comprehensive care. By knowing the specific side effects of medications like anastrozole, nurses can anticipate and manage potential issues, improving patient outcomes and quality of life. Patient education about expected side effects is crucial to ensure adherence to treatment and timely reporting of any concerning symptoms.

Correct Answer: A

Rationale: In this scenario, option A is the most concerning finding that should be reported to the provider. An irregularly shaped, nontender lump in the breast raises suspicion for a potential breast pathology, such as a tumor or mass, which warrants further evaluation and investigation to rule out malignancy. Options B, C, and D are not as concerning as option A. Option B, tenderness during menstruation, is a common physiological finding related to hormonal changes and is not typically indicative of a serious issue. Option C describes bilateral, symmetrical lumps that move with palpation, which are more likely to be benign findings like fibrocystic changes. Option D, reporting breast tenderness before menstruation, is also a common symptom related to hormonal fluctuations and is not typically alarming. Educationally, understanding the significance of different breast examination findings is crucial for nurses caring for women's health. Recognizing abnormal findings and knowing when to escalate concerns to the healthcare provider is essential in early detection and management of breast conditions, including breast cancer. Regular breast assessments and knowledge of normal versus abnormal variations empower nurses to provide comprehensive and timely care to their clients.