During auscultation of fetal heart tones (FHTs), the nurse determines that the heart rate is 136 beats per minute. The nurse's next action should be to:

Correct Answer: A

Rationale: The normal fetal heart rate falls between 110 and 160 beats per minute, so the nurse should document the results as within the normal range. There is no indication of fetal distress based on the heart rate provided. Verifying with the maternal pulse or having the patient change positions is unnecessary in this scenario.

Correct Answer: B

Rationale: When planning care for a client, it is essential for the nurse to consider all aspects of the client's situation. In this case, the correct answer is B: conflict with family over gender expression. This is the most important problem to address because family support and understanding play a crucial role in the well-being of the client, especially when it comes to issues related to gender identity. Addressing conflicts with the family over gender expression can help create a supportive environment for the client to explore and express their identity freely. It can also improve communication and relationships within the family, which are essential for the client's overall health and well-being. Choice A, conflict with gender identity, while important, may not be the immediate priority in this case. The client's internal struggles with their gender identity can be addressed and supported after addressing the external conflicts with the family. Choices C and D are incorrect because they do not directly address the interpersonal relationships and support systems that are crucial for the client's well-being. While addressing financial concerns and access to healthcare are important aspects of care, they are not as pressing as resolving conflicts with the family over gender expression in this particular scenario.

Correct Answer: A

Rationale: A: This statement is correct because it emphasizes the importance of screening clients for safety in order to offer help. Assessing for intimate partner violence is crucial in healthcare settings to ensure the safety and well-being of clients. By acknowledging the policy to screen for safety, the nurse is demonstrating a commitment to identifying and addressing potential abuse. B: While it is true that abuse is common in people who are pregnant, this statement does not directly address the nurse's role in assessing for intimate partner violence. It is important for healthcare providers to be aware of the increased vulnerability of pregnant individuals to intimate partner violence, but this statement does not focus on the nurse's responsibility to screen for safety. C: This statement is also true - it is common for people to hide abusive relationships from others. However, it does not directly address the nurse's role in assessing for intimate partner violence. While recognizing that individuals may hide abusive relationships is important, the primary focus should be on actively screening for signs of abuse and offering support. D: This statement is inappropriate and insensitive. Making assumptions about someone's appearance, such as implying they were in a fight, can be stigmatizing and may deter the client from disclosing potential abuse. It is important for nurses to approach the assessment of intimate partner violence with sensitivity and without making assumptions based on appearance.

Correct Answer: A

Rationale: Option A is the correct answer because a vaccine has been approved to prevent the human papillomavirus (HPV), which is a sexually transmitted infection (STI). The HPV vaccine is recommended for both males and females to prevent certain types of HPV that can lead to genital warts and various types of cancer, including cervical, vaginal, vulvar, anal, and throat cancer. Option B is incorrect because there are vaccines available for some STIs, such as HPV, hepatitis A, and hepatitis B. It is essential for the nurse to provide accurate information to the individual asking about STI vaccines to promote preventive health practices. Option C is partially correct because vaccines are indeed available for hepatitis A, hepatitis B, and HPV. However, this option fails to mention other STIs like HIV and herpes simplex virus (HSV), which do not have vaccines available for prevention. Option D is incorrect because vaccines for HIV and HSV are still under development and not yet approved for prevention. It is crucial for the nurse to stay updated on current research and recommendations regarding STI prevention to provide the most accurate information to patients inquiring about vaccines for STIs.

Correct Answer: A

Rationale: A colposcopy is a procedure performed to closely examine the cervix, vagina, and vulva for signs of disease. The nurse should inform the client that the test is conducted because of abnormal results in a Papanicolaou (Pap) test. This is important because abnormal Pap test results can indicate precancerous or cancerous changes in the cervix, which require further evaluation through a colposcopy. Choice B is incorrect because a colposcopy is typically not a painful procedure. While some women may experience mild discomfort, it is usually well-tolerated without the need for recovery time. It is important for the nurse to reassure the client that discomfort during the procedure is minimal. Choice C is incorrect because intercourse does not need to be avoided for a week after a colposcopy. The client may resume normal activities, including sexual intercourse, as soon as they feel comfortable. It is essential for the nurse to provide accurate information to the client to alleviate unnecessary concerns or restrictions. Choice D is incorrect because a colposcopy may be necessary even without the presence of symptoms. The purpose of a colposcopy is to further investigate abnormal Pap test results, regardless of whether the client is experiencing symptoms. It is crucial for the nurse to educate the client on the importance of follow-up testing to detect and treat any abnormalities early. In conclusion, the nurse should inform the client that a colposcopy is conducted due to abnormal Pap test results, reassure them that the procedure is typically not painful, clarify that intercourse can be resumed as soon as comfortable, and emphasize the importance of undergoing a colposcopy based on Pap test results rather than symptoms.