Nokea
A nurse in labor and delivery is caring for a client. Following delivery of the placenta, the nurse examines the umbilical cord. Which of the following vessels should the nurse expect to observe in the umbilical cord?
- A. Two veins and one artery
- B. One artery and one vein
- C. Two arteries and one veins
Correct Answer: C
Rationale: The correct answer is C: Two arteries and one vein. The umbilical cord typically contains two arteries (carrying deoxygenated blood from the fetus to the placenta) and one vein (carrying oxygenated blood from the placenta to the fetus). This is known as the "AVA" pattern. This configuration is essential for fetal circulation and oxygenation. Option A is incorrect as it has two veins and one artery, which is not the norm. Option B is also incorrect as it has one artery and one vein, missing one artery. Option D is incomplete, so it is also incorrect. Ultimately, the presence of two arteries and one vein in the umbilical cord is the correct and expected vascular arrangement for fetal circulation.
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The nurse is assessing a client in labor and notes persistent late decelerations on the monitor. What is the priority action?
- A. Reposition the client to her left side.
- B. Administer oxygen via face mask.
- C. Increase IV fluids.
- D. Notify the healthcare provider.
Correct Answer: A
Rationale: The correct answer is A: Reposition the client to her left side. This is the priority action because late decelerations indicate uteroplacental insufficiency, possibly due to compression of the umbilical cord. Repositioning the client to her left side can help improve blood flow to the placenta by reducing pressure on the vena cava, thus optimizing fetal oxygenation. Administering oxygen (B) is important but not the immediate priority. Increasing IV fluids (C) may not directly address the cause of late decelerations. Notifying the healthcare provider (D) is important but should come after immediate interventions.
The nurse is assessing a client with suspected preterm labor. Which finding confirms the diagnosis?
- A. Regular uterine contractions every 10 minutes.
- B. Cervical dilation of 3 cm.
- C. Lower back pain and cramping.
- D. Positive fetal fibronectin test.
Correct Answer: B
Rationale: The correct answer is B: Cervical dilation of 3 cm. This finding confirms preterm labor as it indicates cervical changes associated with labor progression. Regular uterine contractions every 10 minutes (choice A) may suggest labor but alone doesn't confirm preterm labor. Lower back pain and cramping (choice C) are common symptoms but not specific to preterm labor. A positive fetal fibronectin test (choice D) may indicate an increased risk of preterm labor but doesn't confirm the diagnosis definitively.
A nurse is teaching the parents of a newborn how to care for their child's uncircumcised penis. Which of the following instructions should the nurse include?
- A. Retract the foreskin until you feel resistance.
- B. Use a cotton swab to clean under the foreskin.
- C. Apply petroleum jelly to the foreskin.
- D. Wash the penis once per day with soup and water.
Correct Answer: D
Rationale: The correct answer is D because washing the penis once per day with soap and water is the appropriate way to care for an uncircumcised penis. This helps maintain good hygiene and prevents infections. Retracting the foreskin forcefully (Choice A) can cause injury and should not be done until the child is older. Using a cotton swab (Choice B) can leave fibers behind and may cause irritation. Applying petroleum jelly (Choice C) is unnecessary and can increase the risk of infections. Therefore, washing the penis with soap and water daily is the most effective and safe method for caring for an uncircumcised penis.
A client in the second stage of labor reports intense rectal pressure. What does this finding indicate?
- A. The baby is in a breech position.
- B. Cervical dilation is incomplete.
- C. The baby is descending into the birth canal.
- D. Labor contractions are ineffective.
Correct Answer: C
Rationale: Step 1: In the second stage of labor, the baby is descending into the birth canal for delivery.
Step 2: Intense rectal pressure is a common sensation as the baby moves down.
Step 3: This indicates progress in labor as the baby is descending.
Step 4: Choice A is incorrect as breech position presents differently.
Step 5: Choice B is incorrect as incomplete cervical dilation may not cause rectal pressure.
Step 6: Choice D is incorrect as effective labor contractions are needed for descent.
What is a common preconception risk factor that can impact pregnancy outcomes?
- A. lack of exercise prior to pregnancy
- B. chronic caffeine intake
- C. high fat diet
- D. lack of immunizations
Correct Answer: D
Rationale: The correct answer is D, lack of immunizations. Immunizations protect pregnant individuals from serious infections that can harm both the mother and the baby. Infections like influenza and pertussis can lead to complications such as preterm birth, low birth weight, and even fetal death. Ensuring that pregnant individuals are up to date on their immunizations helps safeguard their health and the health of their unborn child.
Choice A, lack of exercise, may impact pregnancy outcomes, but it is not as significant as the risk posed by lack of immunizations in terms of preventing serious complications. Chronic caffeine intake (Choice B) and high-fat diet (Choice C) can also have negative effects on pregnancy outcomes, but they are not as directly linked to potential harm for the mother and baby as the lack of immunizations.