Nokea
A breastfeeding client asks the nurse to make sure that her newborn is positioned and latched well at the breast. Which of the following assessments would indicate that the baby is poorly latched?
- A. The baby swallows after every suckle.
- B. The baby’s body is facing the mother’s body.
- C. The baby’s lower lip is curled under.
- D. The baby is lying at the level of the mother’s breasts.
Correct Answer: C
Rationale: A curled-under lower lip indicates poor latching, which can lead to ineffective feeding and nipple damage.
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Which advice to the patient is one of the most effective methods for preventing venous stasis?
- A. Sit with the legs crossed.
- B. Rest often with the feet elevated.
- C. Sleep with the foot of the bed elevated.
- D. Wear elastic stockings in the afternoon.
Correct Answer: B
Rationale: The correct answer is B: Rest often with the feet elevated. Elevating the feet helps to promote venous blood flow back to the heart, reducing the risk of venous stasis. When the legs are elevated, gravity assists in returning the blood to the heart. Sitting with the legs crossed (choice A) can actually impede blood flow. Sleeping with the foot of the bed elevated (choice C) may not be as effective as regularly elevating the feet throughout the day. Wearing elastic stockings in the afternoon (choice D) can provide some support but may not be as effective as elevating the feet.
The nurse is measuring the fundal height of a patient who is at 34 weeks of gestation. What fundal height measurement is expected for a patient who is at 34 weeks of gestation?
- A. 31 cm
- B. 33 cm
- C. 37 cm
- D. 38 cm
Correct Answer: C
Rationale: The correct answer is C (37 cm) because at 34 weeks of gestation, the fundal height measurement should be approximately equal to the number of weeks of gestation in centimeters. This is known as the "fundal height equals gestational age" rule. Therefore, at 34 weeks, the expected fundal height measurement should be around 34 cm. Option C (37 cm) is the closest to this expected measurement. Options A, B, and D are incorrect as they do not align with the fundal height expected at 34 weeks of gestation. Option A (31 cm) is too low, Option B (33 cm) is also lower than expected, and Option D (38 cm) is too high for 34 weeks of gestation.
A client asks the nurse to explain what luteinizing hormone (LH) does in the body. The nurse explains which of the following?
- A. It accelerates the growth and maturation of an egg in your ovary.'
- B. It enhances the potential for the sperm to fertilize the mature egg.'
- C. It promotes the movement of the egg through the fallopian tube.'
- D. It stimulates the monthly release of a mature egg from your ovary.'
Correct Answer: D
Rationale: LH surge triggers ovulation, the release of a mature egg from the ovary.
The nurse is discussing pregnancy concerns with a patient in the third trimester of pregnancy. What warning sign should the nurse teach the patient to report immediately to the health-care provider?
- A. chronic constipation
- B. decreased fetal movement
- C. early evening fatigue
- D. loss of appetite
Correct Answer: B
Rationale: The correct answer is B: decreased fetal movement. This warning sign is crucial in the third trimester as it could indicate fetal distress or other complications requiring prompt medical attention. Decreased fetal movement can be a sign of potential problems with the baby's health and should not be ignored. Chronic constipation (A), early evening fatigue (C), and loss of appetite (D) are common pregnancy symptoms but are not typically considered urgent warning signs that require immediate reporting to the healthcare provider. It is important for the nurse to emphasize the significance of monitoring fetal movements and seeking medical advice promptly if there is a noticeable decrease.
The nurse is preparing to assist with the insertion of an intrauterine pressure catheter and a fetal spiral electrode. What is required for proper placement by the practitioner? Select all that apply.
- A. Rupture of membranes
- B. Dilated cervix
- C. Vertex fetus
- D. Moderate variability
Correct Answer: A
Rationale: Correct Answer: A - Rupture of membranes
Rationale:
1. Rupture of membranes is necessary for the insertion of intrauterine pressure catheter and fetal spiral electrode.
2. It allows safe passage of the catheter and electrode into the uterus.
3. Without ruptured membranes, there is a risk of infection and difficulty in inserting the devices.
Summary:
- Choice B (Dilated cervix) is not required for the insertion of these devices.
- Choice C (Vertex fetus) is not a factor in the insertion process.
- Choice D (Moderate variability) is related to fetal heart rate monitoring, not device insertion.