Nokea
A 32-week-gravid client presents in the emergency department with severe abdominal pain, rigid abdomen, and scant dark red bleeding. The nurse should assess this client for which of the following?
- A. Signs of pulmonary edema.
- B. Enlarging abdominal girth measurements.
- C. Hyporeflexia and confusion.
- D. Signs of diabetic coma and ketosis.
Correct Answer: B
Rationale: Severe abdominal pain, rigidity, and dark red bleeding could indicate placental abruption, which may cause enlarging abdominal girth due to internal bleeding.
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The nurse is performing Leopold's maneuvers on a pregnant patient at 36 weeks of gestation and determines the fetal lie is longitudinal, palpates the fetal legs in the top of the uterus, and palpates the fetal head above the symphysis pubis. Which fetal presentation does the nurse document in the EHR?
- A. cephalic
- B. compound
- C. transverse
- D. breech
Correct Answer: D
Rationale: The correct answer is D: breech. At 36 weeks of gestation, if the nurse palpates the fetal head above the symphysis pubis and the fetal legs are at the top of the uterus, it indicates a breech presentation where the baby's buttocks or feet are positioned to be delivered first. In a breech presentation, the fetal head is not engaged in the pelvis and is palpable above the symphysis pubis. The longitudinal lie with the fetal legs on top further supports the breech presentation.
Summary:
A: Cephalic presentation would have the fetal head engaged in the pelvis.
B: Compound presentation involves an additional body part alongside the presenting part.
C: Transverse lie would have the baby positioned horizontally across the uterus.
D: Breech presentation aligns with the given scenario of palpating fetal legs on top and head above the symphysis pubis.
What is the purpose of initiating contractions in a contraction stress test (CST)?
- A. Increase placental blood flow.
- B. Identify fetal acceleration patterns.
- C. Determine the degree of fetal activity.
- D. Apply a stressful stimulus to the fetus.
Correct Answer: D
Rationale: The purpose of initiating contractions in a contraction stress test (CST) is to apply a stressful stimulus to the fetus to assess its response to stress, mimicking the stress of labor. This helps evaluate fetal well-being by monitoring the fetal heart rate during contractions. A: Increasing placental blood flow is not the primary purpose of CST. B: Identifying fetal acceleration patterns is not the main goal of CST. C: Determining the degree of fetal activity is not the primary objective of CST. The correct answer is D as it reflects the main purpose of initiating contractions in a CST.
A woman and man have the following genotypes for an autosomal dominant disease: Aa and Aa. If asked, which of the following should the nurse say is the probability of their child having the disease?
- A. 25% probability.
- B. 50% probability.
- C. 75% probability.
- D. 100% probability.
Correct Answer: C
Rationale: The probability of their child having the disease is 75% because both parents are carriers (Aa). The possible genotypes for the child are AA, Aa, aA, and aa. Only the aa genotype would not result in the disease, giving a 75% chance of the child having the disease.
The nurse is teaching her client about the methods of electronic fetal monitoring during labor. Her client asks which method has the fewest risks to her baby and allows her the most freedom. What is the most appropriate response by the nurse?
- A. Internal and external monitoring have equal risks. You will have to remain in the bed with both of these methods.'
- B. Internal monitoring is a more invasive method, but we only use internal monitoring if we have difficulty obtaining accurate information with external monitoring.'
- C. External monitoring will allow you the most freedom of movement and does not require any invasive procedures for you or your baby.'
- D. External monitoring is not invasive but you have to remain in the bed.'
Correct Answer: C
Rationale: The correct answer is C because external monitoring allows the client the most freedom of movement and does not require any invasive procedures for her or the baby. External monitoring involves placing sensors on the abdomen to monitor the baby's heart rate and the mother's contractions. This method is non-invasive and allows the mother to move around during labor, promoting comfort and mobility.
Choice A is incorrect because internal monitoring is more invasive than external monitoring. Choice B is incorrect because internal monitoring is not used solely based on difficulty obtaining accurate information with external monitoring. Choice D is incorrect because external monitoring does not require the mother to remain in bed; she can move around freely.
A client’s vital signs during labor and delivery were: BP 100/58–110/66, T 98.6ºF–98.8ºF, P 72–80 bpm, R 20–24 rpm. The client’s vitals 2 hours postpartum are BP 100/56, TPR 99.4ºF, P 70 bpm, R 20 rpm. Which of the following actions should the nurse perform at this time?
- A. Check the client’s lochia flow.
- B. Ask the client if she is having chills.
- C. Encourage the client to drink fluids.
- D. Assess the client’s lung fields.
Correct Answer: A
Rationale: Checking the client’s lochia flow is important to ensure there is no excessive bleeding, which could indicate postpartum hemorrhage.