Nokea
The nurse is educating a client about signs of preterm labor. What symptom should be reported immediately?
- A. Frequent urination.
- B. Low back pain and cramping.
- C. Increased appetite.
- D. Braxton Hicks contractions.
Correct Answer: B
Rationale: Low back pain and cramping can indicate preterm labor and should be reported immediately for further evaluation.
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A client at 16 weeks' gestation asks about the purpose of a maternal serum alpha-fetoprotein (MSAFP) test. What is the nurse's best response?
- A. It screens for chromosomal abnormalities.
- B. It detects neural tube defects.
- C. It confirms the gestational age of the baby.
- D. It identifies the baby's sex.
Correct Answer: B
Rationale: The MSAFP test is used to screen for neural tube defects such as spina bifida.
A patient who has an LNG-IUC in place calls the office and states she just took a pregnancy test, and it is positive. She comes in for a visit, and the nurse does another pregnancy test, which is positive. What does the nurse know that the clinician will inform the patient regarding the IUC?
- A. Removing the IUC may increase the chance of infertility.
- B. The fetus is at risk for congenital defects.
- C. The IUC needs to be removed regardless of the plans for this pregnancy.
- D. There is no risk to the fetus if the IUC is left in place.
Correct Answer: D
Rationale: The correct statement the nurse knows that the clinician will inform the patient regarding the LNG-IUC is that there is no risk to the fetus if the IUC is left in place. The LNG-IUC (levonorgestrel-releasing intrauterine system) is a highly effective form of contraception that works by releasing progesterone locally in the uterus. The hormonal effect of the LNG-IUC is mostly limited to the uterus and very little of it circulates systemically. Therefore, there is no known increased risk of congenital defects or harm to the fetus if the IUC is left in place during pregnancy. The IUC can be left in place if the patient chooses to continue the pregnancy, provided there are no signs of infection or other complications that would necessitate its removal.
A nurse is caring for a client who is receiving oxytocin to augment labor. The nurse notes recurrent variable decelerations...Which of the following actions should the nurse take first?
- A. Prepare the equipment necessary to initiate an amnioinfusion.
- B. Administer oxygen at 10 L/min via nonrebreather face mask.
- C. Discontinue the infusion of oxytocin.
- D. Place the client in a left lateral position.
Correct Answer: C
Rationale: Recurrent variable decelerations during labor can indicate umbilical cord compression, which can result in fetal hypoxia and distress. Discontinuing the oxytocin infusion is the priority in this situation as oxytocin can cause or exacerbate uteroplacental insufficiency leading to fetal distress. By discontinuing the oxytocin, the nurse can help improve fetal oxygenation and alleviate the variable decelerations. After stopping the oxytocin infusion, the nurse should continue to monitor the fetal heart rate pattern and follow the healthcare provider's orders for further management if needed.
After her baby's birth a patient wishes to begin breastfeeding. The nurse assists the client by:
- A. Positioning the infant to grasp the nipple to express milk.
- B. Giving the infant a bottle first to evaluate the baby's ability to suck
- C. Leaving them alone and allowing the infant to nurse as long as desired
- D. Touching the infant's cheek adjacent to the nipple to elicit the rooting reflex
Correct Answer: A
Rationale: Positioning the infant to grasp the nipple to express milk is an essential step in helping the patient begin breastfeeding successfully. As a nurse, it is crucial to ensure that the infant is properly latched onto the breast to facilitate effective feeding and milk transfer. This involves positioning the infant in a way that allows them to effectively grasp the nipple, promoting proper suckling and milk production. By assisting the patient in positioning the infant correctly, the nurse is supporting the establishment of successful breastfeeding and ensuring optimal nutrition for the baby.
The nurse is caring for a client with severe preeclampsia. What finding would indicate magnesium sulfate toxicity?
- A. Increased deep tendon reflexes.
- B. Respiratory rate of 10 breaths per minute.
- C. Urine output of 50 mL/hour.
- D. Blood pressure of 160/110 mmHg.
Correct Answer: B
Rationale: Respiratory depression is a key sign of magnesium sulfate toxicity, requiring immediate action.