Nokea
Which assessment finding suggests that the laboring client's
- B. Reflex grade 0
- C. Urine output 60
- D. Generalized seizure
Correct Answer: D
Rationale: The correct answer is D, Generalized seizure. During labor, a generalized seizure is a critical finding that indicates eclampsia, a severe complication of pregnancy characterized by seizures, hypertension, and proteinuria. This requires immediate medical intervention to prevent harm to the mother and baby. Reflex grade 0 (choice B) is not a typical assessment finding during labor, and it does not indicate any immediate life-threatening condition. Urine output of 60 (choice C) is within the normal range and does not suggest any immediate critical issue. Therefore, choice D is the correct answer due to the urgency and severity of the condition it represents.
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What is a statement that best describes reproductive health?
- A. Reproductive health focuses solely on the ability to reproduce and have children.
- B. Reproductive health encompasses physical well-being but does not include mental and social aspects.
- C. Reproductive health involves complete physical, mental, and social well-being related to the reproductive system.
- D. Reproductive health is limited to making informed decisions about contraception methods.
Correct Answer: C
Rationale: The correct answer is C because reproductive health is not just about the ability to reproduce but also includes mental and social well-being. This choice aligns with the World Health Organization's definition of reproductive health, which emphasizes holistic well-being. Choice A is incorrect as it oversimplifies reproductive health. Choice B is incorrect because reproductive health should address all aspects of well-being. Choice D is incorrect as reproductive health goes beyond just contraception to encompass a broader scope of health and well-being.
How can a nurse best prevent heat loss in a newborn during the first hour of life?
- A. Place the newborn under a radiant warmer
- B. Dry the newborn and cover with a warm blanket
- C. Place the newborn in a skin-to-skin position with the mother
- D. Keep the newborn wrapped in a wet blanket
Correct Answer: A
Rationale: The correct answer is A: Place the newborn under a radiant warmer. This method is the most effective in preventing heat loss in a newborn as radiant warmers provide a consistent heat source to maintain the newborn's body temperature. This is crucial during the first hour of life when newborns are at a higher risk of hypothermia.
Choice B is not as effective as using a radiant warmer as it may not provide enough warmth to prevent heat loss. Choice C, placing the newborn in a skin-to-skin position with the mother, is beneficial for bonding and regulating the newborn's temperature in the long term but may not be as effective as a radiant warmer in the immediate post-birth period.
Choice D, keeping the newborn wrapped in a wet blanket, is incorrect as wet blankets can further contribute to heat loss through evaporative cooling. In summary, using a radiant warmer is the best option for preventing heat loss in a newborn during the critical first hour of life.
A nurse is caring for a client who experienced a cesarean birth due to dysfunctional labor. The client states that she is disappointed that she did not have natural childbirth. Which of the following responses should the nurse make?
- A. "It sounds like you are feeling sad that things didn't go as planned."
- B. "At least you know you have a healthy baby."
- C. "Maybe next time you can have a vaginal delivery."
- D. "You can resume sexual relations sooner than if you had delivered vaginally."
Correct Answer: A
Rationale: Step 1: Empathy - The nurse acknowledges the client's feelings of disappointment, showing empathy and understanding.
Step 2: Validation - By stating "It sounds like you are feeling sad that things didn't go as planned," the nurse validates the client's emotions, making her feel heard and supported.
Step 3: Therapeutic Communication - This response encourages the client to express her feelings further, promoting open communication and trust in the nurse-client relationship.
Summary:
Choice B is incorrect as it dismisses the client's emotional concerns and focuses solely on the baby's health. Choice C is incorrect as it minimizes the client's current experience and may increase feelings of inadequacy. Choice D is incorrect as it is not relevant to the client's emotional needs and may be perceived as insensitive.
A nurse is teaching a client who is at 41 weeks of gestation about a non-stress test. Which of the following information should the nurse include in the teaching?
- A. "This test will confirm fetal lung maturity ".
- B. "This test will determine adequacy of placental perfusion".
- C. "This test will detect fetal infection".
- D. "This test will predict maternal readiness for labor".
Correct Answer: B
Rationale: The correct answer is B: "This test will determine adequacy of placental perfusion." The non-stress test is used to assess fetal well-being by monitoring fetal heart rate in response to fetal movement. It helps determine if the placenta is providing enough oxygen and nutrients to the fetus. This information is crucial in assessing the overall health and viability of the fetus.
A: "This test will confirm fetal lung maturity" - This statement is incorrect because the non-stress test does not assess fetal lung maturity. That is usually done through tests like amniocentesis.
C: "This test will detect fetal infection" - This statement is incorrect because the non-stress test does not detect fetal infection. Other tests like amniocentesis or blood tests are used for this purpose.
D: "This test will predict maternal readiness for labor" - This statement is incorrect as the non-stress test focuses on fetal well-being and does not predict maternal readiness for labor.
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.