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A nurse monitors fetal well-being by means of an external monitor. At the peak of the contractions, the fetal heart rate has repeatedly dropped 30 beats/min below the baseline. Late decelerations are suspected and the nurse notifies the physician. Which is the rationale for this action?
- A. A nuchal cord (cord around the neck) is associated with variable decelerations, not late decelerations.
- B. Variable decelerations (not late decelerations) are associated with cord compression.
- C. Late decelerations are a result of hypoxia. They are not reflective of the strength of maternal contractions.
- D. Late decelerations are associated with uteroplacental insufficiency and are a sign of fetal hypoxia. Repeated late decelerations indicate fetal distress.
Correct Answer: D
Rationale: The correct answer is D because late decelerations are associated with uteroplacental insufficiency, resulting in fetal hypoxia. This is a sign of fetal distress, as indicated by the repeated drops in fetal heart rate during contractions. Late decelerations occur after the peak of the contraction, reflecting the delayed recovery of the fetal heart rate due to inadequate oxygen supply from the placenta. This prompts the nurse to notify the physician for further evaluation and intervention to address the underlying cause of fetal distress. Choices A, B, and C are incorrect because they do not accurately describe the characteristics and causes of late decelerations in fetal monitoring.
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A nurse is reviewing discharge teaching with the parents of a child who has pediculosis.Which of the following should the nurse include in the teaching?
- A. "Children can share scarves and coats ,but not hats or combs."'
- B. "Household pets can carry and transmit lice to people."'
- C. "After washing clothing,hang clothes outside to dry."'
- D. "Seal nonwashable items in plastic bags for 14 days."'
Correct Answer: D
Rationale: The correct answer is D. The nurse should include sealing nonwashable items in plastic bags for 14 days in the teaching for pediculosis. This is important to prevent reinfestation as lice can survive for up to 48 hours without a host. By sealing items in plastic bags for 14 days, any remaining lice or eggs will die off.
Choice A is incorrect because lice can be transmitted through shared hats and combs, not just scarves and coats. Choice B is incorrect as lice do not live on household pets. Choice C is incorrect as hanging clothes outside will not effectively eliminate lice.
A nurse is caring for a child with measles.
- A. "Provide diversional activities such as video games."'
- B. "Maintain isolation for 48 hr after the rash resolves."'
- C. "Keep the child warm with adequate undergarments and bedding."'
- D. "Administer vitamin A supplements as prescribed."'
Correct Answer: D
Rationale: The correct answer is D because administering vitamin A supplements is a standard treatment for measles to reduce complications and improve recovery. Vitamin A deficiency is common in children with measles, and supplementation can help boost the immune system and reduce the severity of the illness. Providing diversional activities (choice A) may be suitable but does not directly address the medical needs of the child. Maintaining isolation (choice B) is important but typically lasts until 4 days after rash onset, not just 48 hours after rash resolution. Keeping the child warm (choice C) is a general comfort measure and may not directly impact measles treatment.
A nurse in a prenatal clinic who reports that her menstrual period is 2 wks late. The client appears anxious and asks the nurse if she is pregnant. Which of the following responses should the nurse make?
- A. You can miss your period for several other reasons, describe your typical menstrual cycle.
- B. If you have been sexually active and haven't used protection, it is likely that you are pregnant.
- C. Let's check to see if you have any other signs of pregnancy, have you noticed any abdominal enlargement yet?
- D. Because you have missed your period, you should try taking a home pregnancy test before you start worrying.
Correct Answer: A
Rationale: Correct Answer: A
Rationale: Response A is the most appropriate because it addresses the client's concerns while also gathering more information. By asking the client to describe her typical menstrual cycle, the nurse can explore other potential reasons for the missed period, such as stress or hormonal imbalances. This approach shows empathy and helps the nurse to provide personalized care based on the client's individual situation.
Summary of Other Choices:
B: This response assumes pregnancy without gathering more information or considering other possibilities, potentially causing unnecessary worry or anxiety.
C: Asking about abdominal enlargement is a specific sign of pregnancy and may not be relevant at this early stage. It also does not address the client's anxiety directly.
D: While suggesting a home pregnancy test is important, it does not address the client's anxiety or gather more information about her menstrual cycle.
Which fetal structure is responsible for carrying oxygenated blood from the placenta to the fetus?
- A. Ductus arteriosus
- B. Umbilical artery
- C. Portal vein
- D. Umbilical vein
Correct Answer: D
Rationale: The correct answer is D: Umbilical vein. The umbilical vein carries oxygenated blood from the placenta to the fetus. This is because the placenta acts as the organ of gas exchange during fetal development. Oxygenated blood from the mother is transferred to the fetus through the umbilical vein. The other choices are incorrect because: A) Ductus arteriosus is a fetal blood vessel that connects the pulmonary artery to the aorta, bypassing the lungs. B) Umbilical artery carries deoxygenated blood from the fetus to the placenta. C) Portal vein carries nutrient-rich blood from the intestines to the liver, not from the placenta to the fetus.
A nurse is reinforcing teaching to a group of parents about preventing accidental poisoning in preschoolers.
- A. "Have syrup of ipecac available in the home."'
- B. "Explain to preschool children that plants can be eaten only after they are cooked."'
- C. "Keep labels on containers of toxic substances and never remove them."'
- D. "Place medications in a cabinet above the sink."'
Correct Answer: C
Rationale: The correct answer is C. Keeping labels on containers of toxic substances is crucial as it provides important information about the contents and hazards. Removing labels can lead to confusion and accidental ingestion. Syrup of ipecac (choice A) is no longer recommended for poisoning treatment. Teaching children to eat cooked plants (choice B) does not address the issue of accidental poisoning. Placing medications above the sink (choice D) may still be accessible to preschoolers.