Nokea
A nurse is assessing a newborn who was born Post term. Which of the following findings should the nurse expect?
- A. A Rh-negative mother who has an Rh- positive infant
- B. A Rh "“positive mother who has an Rh- negative infant
- C. A Rh-positive mother who has an Rh- positive infant
- D. A Rh- negative mother who has an Rh- negative infant
Correct Answer: A
Rationale: The correct answer is A: A Rh-negative mother who has an Rh-positive infant. Post-term infants are at higher risk for conditions such as Rh incompatibility. Since the mother is Rh-negative and the infant is Rh-positive, there is a potential for Rh incompatibility, leading to hemolytic disease of the newborn. This occurs when the mother's antibodies attack the infant's red blood cells.
Choice B is incorrect because Rh incompatibility occurs when the mother is Rh-negative and the infant is Rh-positive. Choice C is incorrect as both mother and infant being Rh-positive do not lead to Rh incompatibility. Choice D is incorrect because Rh incompatibility does not occur when both mother and infant are Rh-negative.
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A nurse is caring for a client who experienced a vaginal birth 3 hr ago. Upon palpation, the fundus is displaced to the right of midline, is firm, and is two fingerbreadths above the umbilicus. Which of the following actions should the nurse complete at this time?
- A. Massage the fundus.
- B. Insert a urinary catheter.
- C. Have the client urinate.
- D. Administer an analgesic.
Correct Answer: C
Rationale: Correct Answer: C - Have the client urinate.
Rationale:
1. Displacement to the right of midline indicates a full bladder pushing the fundus.
2. A full bladder can prevent the fundus from contracting properly.
3. Having the client urinate will help the bladder empty, allowing the fundus to contract effectively and prevent complications like postpartum hemorrhage.
Summary of Incorrect Choices:
A: Massaging the fundus is not necessary as it is already firm.
B: Inserting a urinary catheter is invasive and should be avoided unless necessary.
D: Administering an analgesic is not indicated for fundus displacement; addressing the full bladder is the priority.
A client at 28 weeks' gestation is undergoing a glucose tolerance test. What is the purpose of this test?
- A. To detect anemia.
- B. To screen for gestational diabetes.
- C. To assess fetal growth.
- D. To evaluate placental function.
Correct Answer: B
Rationale: The correct answer is B: To screen for gestational diabetes. The glucose tolerance test during pregnancy helps to identify women at risk for developing gestational diabetes, a condition that can lead to complications for both the mother and baby. By measuring blood sugar levels after consuming a glucose solution, healthcare providers can assess how the body processes sugar during pregnancy. This test is specifically designed to detect abnormalities in glucose metabolism during pregnancy.
Choice A: To detect anemia - Anemia is not typically identified through a glucose tolerance test. Anemia is usually diagnosed through a blood test that measures hemoglobin levels.
Choice C: To assess fetal growth - Fetal growth is usually monitored through ultrasound scans and measurements, not through a glucose tolerance test.
Choice D: To evaluate placental function - Placental function is evaluated through other tests like Doppler ultrasound, not through a glucose tolerance test.
A nurse is caring for a client who is in active labor and notes late decelerations in the FRH on the external fetal.... Which of the following actions should the nurse take first?
- A. Change the client's position.
- B. Palpate the uterus to assess for tachysystole.
- C. Increase the client's IV infusion rate.
- D. Administer oxygen at 10 L/min via nonrebreather mask.
Correct Answer: A
Rationale: The correct answer is A: Change the client's position. Late decelerations indicate uteroplacental insufficiency, which can be caused by pressure on the vena cava from the uterus. Changing the client's position can alleviate this pressure, improving fetal oxygenation. Palpating the uterus or increasing IV infusion rate may not address the underlying issue. Administering oxygen is important but should come after addressing the positional issue to ensure optimal oxygen delivery to the fetus.
What hormone is responsible for the development and maturation of the ovarian follicles?
- A. follicle-stimulating hormone (FSH)
- B. luteinizing hormone (LH)
- C. estrogen
- D. progesterone
Correct Answer: A
Rationale: Rationale: Follicle-stimulating hormone (FSH) is responsible for the development and maturation of ovarian follicles by stimulating them to grow and produce estrogen. FSH plays a crucial role in the menstrual cycle and acts on the ovaries to promote follicular development. LH surge triggers ovulation, estrogen is produced by the developing follicles and progesterone is primarily produced after ovulation by the corpus luteum. Therefore, A is correct as it directly influences the growth and maturation of ovarian follicles.
A woman had a miscarriage at 12 weeks' gestation and had D&C,
- A. While you are assessing her response to loss, she tells you she had
- B. Based on your assessment what nursing intervention would you use first?
- C. You ask her what items she bought for the baby
Correct Answer: B
Rationale: The correct answer is B because the priority in nursing care after a miscarriage and D&C is to assess the woman's physical and emotional well-being. By using the nursing intervention of assessment first, the nurse can determine any immediate needs for pain management, emotional support, or further medical intervention. This helps in providing individualized care and addressing any potential complications promptly.
Choice A is incorrect because assessing her response to loss comes after ensuring her immediate physical and emotional needs are met. Choice C is incorrect as it focuses on material items rather than the woman's well-being. Choice D is incomplete and does not provide a viable option for nursing intervention.