Nokea
Amniotic fluid index of 18 cm in the 3rd trimester is interpreted as:
- A. Hydrops fetalis
- B. Normal amniotic fluid volume
- C. Reduced amniotic fluid volume
- D. Increased amniotic fluid volume
Correct Answer: B
Rationale: The correct answer is B: Normal amniotic fluid volume. An amniotic fluid index of 18 cm in the 3rd trimester is considered within the normal range (5-25 cm). This level indicates adequate amniotic fluid for fetal development and is not indicative of hydrops fetalis (A), reduced amniotic fluid volume (C), or increased amniotic fluid volume (D). It is crucial to monitor amniotic fluid levels as deviations from the normal range can impact fetal well-being.
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All of the following are elements of the postpartum breast assessment EXCEPT:
- A. firmness, tenderness, and redness
- B. engorgement and nipple soreness/cracking
- C. lumps indicating possible cancerous growths
Correct Answer: C
Rationale: Lumps indicating possible cancerous growths are not typically part of a routine postpartum breast assessment.
You are taking care of a patient who has had a colporrhaphy. Which option would indicate a priority assessment during the postoperative period?
- A. Documentation of a pessary in the operative procedure notes by the physician
- B. Removal of vaginal packing as ordered by the physician
- C. Use of a cell saver for transfusion therapy in the postoperative period
- D. Order for removal of staples 2 to 3 days post-procedure
Correct Answer: B
Rationale: The correct answer is B: Removal of vaginal packing as ordered by the physician. This is a priority assessment because leaving the vaginal packing in place for too long can lead to complications such as infection or tissue damage. It is important to follow the physician's orders for timely removal to prevent these risks.
A: Documentation of a pessary in the operative notes is important for accuracy but not a priority assessment in the postoperative period.
C: The use of a cell saver for transfusion therapy is not directly related to the immediate postoperative care of a colporrhaphy patient and is not a priority assessment in this context.
D: The removal of staples 2 to 3 days post-procedure is important but not as time-sensitive as the removal of vaginal packing. It can be done at a later stage without immediate risk to the patient.
The nurse is explaining the function of the male’s cremaster muscle to a group of nursing students. Which statement accurately describes the function of the cremaster muscle?
- A. Assists with transporting sperm
- B. Aids in temperature control of the testicles
- C. Aids in voluntary control of excretion of urine
- D. Entraps blood in the penis to produce an erection
Correct Answer: B
Rationale: The correct answer is B: Aids in temperature control of the testicles. The cremaster muscle contracts in response to cold temperatures to pull the testicles closer to the body for warmth, and relaxes in warm temperatures to move the testicles away for cooling. This mechanism helps regulate the temperature required for optimal sperm production.
Explanation of why the other choices are incorrect:
A: The cremaster muscle is not directly involved in transporting sperm.
C: The cremaster muscle is not related to the control of urine excretion.
D: The cremaster muscle does not play a role in trapping blood in the penis for an erection.
An Rh-negative mother who has given birth to an Rh-positive infant and has no evidence of sensitization (i.e., maternal indirect Coombs test negative) should be administered
- A. Rh immune globulin (Rhogam) within 72 hours of delivery
- B. no additional medication
- C. cross-matched packed red blood cells within 4 hours of delivery
Correct Answer: A
Rationale: Administering Rh immune globulin prevents maternal sensitization and future hemolytic disease of the newborn.
The layer of the uterus from which tissue is sloughed during menstruation is the:
- A. Endometrium
- B. Myometrium
- C. Parietal peritoneum
- D. Visceral peritoneum
Correct Answer: A
Rationale: The endometrium is the inner lining of the uterus that sheds during menstruation.