Nokea
A client is scheduled for a cesarean birth based on fetal lung maturity. Which finding indicates that the fetal lungs are mature?
- A. Absence of Phosphatidylglycerol (PG)
- B. Biophysical profile score of 8
- C. Lecithin/sphingomyelin (L/S) ratio of 2:1
- D. Reactive nonstress test
Correct Answer: C
Rationale: The correct answer is C: Lecithin/sphingomyelin (L/S) ratio of 2:1. This ratio indicates fetal lung maturity as it signifies adequate production of surfactant in the fetal lungs, essential for proper lung function after birth. Absence of Phosphatidylglycerol (PG) (Choice A) indicates immaturity, Biophysical profile score of 8 (Choice B) assesses overall fetal well-being, not lung maturity, and Reactive nonstress test (Choice D) evaluates fetal well-being, not lung maturity. The L/S ratio of 2:1 is the most reliable indicator of fetal lung maturity.
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After an amniotomy, what is the priority nursing action?
- A. Observe color and consistency of fluid
- B. Assess the fetal heart rate pattern
- C. Assess the client's temperature
- D. Evaluate the client for the presence of chills and increased uterine tenderness using palpation
Correct Answer: B
Rationale: The correct answer is B: Assess the fetal heart rate pattern. After an amniotomy (breaking of the water), the priority is to monitor the fetal well-being to ensure the baby is tolerating the procedure well. Assessing the fetal heart rate pattern helps the nurse determine if the baby is experiencing any distress or changes in oxygenation. This immediate assessment is crucial in identifying any potential complications and taking prompt action.
Observing the color and consistency of fluid (A) is important but not as immediate as assessing the fetal heart rate. Assessing the client's temperature (C) and evaluating for chills and increased uterine tenderness (D) are important but do not address the immediate concern of fetal well-being post-amniotomy.
A client is in the first trimester of pregnancy and lacks immunity to rubella. When should the client receive rubella immunization?
- A. Shortly after giving birth
- B. In the third trimester
- C. Immediately
- D. During the next attempt to get pregnant
Correct Answer: A
Rationale: The correct answer is A. Rubella immunization should be given shortly after giving birth to prevent any potential harm to the fetus during pregnancy. Immunization during pregnancy is contraindicated to avoid any risk of harm to the developing baby. Option B is incorrect as immunization in the third trimester can still pose a risk to the fetus. Option C is incorrect as immediate immunization during pregnancy is not recommended. Option D is incorrect as waiting until the next attempt to get pregnant does not protect the current fetus.
A nurse in a prenatal clinic is caring for a client who is at 7 weeks of gestation. The client reports urinary frequency and asks if this will continue until delivery. Which of the following responses should the nurse make?
- A. It's a minor inconvenience, which you should ignore.
- B. In most cases it only lasts until the 12th week, but it will continue if you have poor bladder tone.
- C. There is no way to predict how long it will last in each individual client.
- D. It occurs during the first trimester and near the end of the pregnancy.
Correct Answer: D
Rationale: The correct answer is D because urinary frequency is common in early pregnancy due to hormonal changes and pressure on the bladder from the growing uterus. This symptom typically improves by the end of the first trimester, as the uterus rises and reduces pressure on the bladder. Therefore, telling the client that it occurs during the first trimester and near the end of pregnancy is accurate.
Choice A is incorrect because urinary frequency should not be ignored as it could be a sign of a urinary tract infection or other underlying issue.
Choice B is incorrect because it inaccurately suggests that urinary frequency only lasts until the 12th week and implies that poor bladder tone is the sole factor influencing this symptom.
Choice C is incorrect because while it is true that individual experiences can vary, there are general patterns and timelines for common pregnancy symptoms like urinary frequency.
A client is being cared for 2 hours after a spontaneous vaginal birth and has saturated two perineal pads with blood in a 30-minute period. Which of the following is the priority nursing intervention at this time?
- A. Palpate the client's uterine fundus.
- B. Assist the client to a bedpan to urinate.
- C. Prepare to administer oxytocic medication.
- D. Increase the client's fluid intake.
Correct Answer: A
Rationale: The correct answer is A: Palpate the client's uterine fundus. Palpating the uterine fundus is crucial to assess for uterine atony, a common cause of postpartum hemorrhage. If the fundus is boggy or deviated, it indicates uterine atony and immediate interventions are needed.
B: Assisting the client to a bedpan to urinate is important, but addressing the potential cause of excessive bleeding takes precedence.
C: Administering oxytocic medication may be necessary to help stimulate uterine contractions, but assessing the fundus comes first to determine the underlying cause of bleeding.
D: Increasing fluid intake is not the priority in this situation. Palpating the fundus and addressing potential hemorrhage are the immediate concerns.
A client who is at 6 weeks of gestation with her first pregnancy asks the nurse when she can expect to experience quickening. Which of the following responses should the nurse make?
- A. This will occur during the last trimester of pregnancy.
- B. This will happen by the end of the first trimester of pregnancy.
- C. This will occur between the fourth and fifth months of pregnancy.
- D. This will happen once the uterus begins to rise out of the pelvis.
Correct Answer: C
Rationale: The correct answer is C: This will occur between the fourth and fifth months of pregnancy. Quickening typically happens around 18-20 weeks, which falls between the fourth and fifth months of pregnancy. During this time, the fetus's movements become more pronounced and can be felt by the pregnant person. Choices A, B, and D are incorrect because quickening does not occur in the last trimester, end of the first trimester, or when the uterus rises out of the pelvis. These options do not align with the typical timing of quickening in pregnancy.