Nokea
A client asks about the risks of the copper IUD. Which of the following would the nurse include?
- A. It may increase menstrual bleeding and cramping.
- B. It causes permanent infertility.
- C. It requires daily replacement.
- D. It increases the risk of breast cancer.
Correct Answer: A
Rationale: The copper IUD may increase menstrual bleeding and cramping, especially initially. It does not cause permanent infertility, require daily replacement, or increase breast cancer risk.
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A client is admitted with a suspected abruptio placentae. The nurse should assess the client for which of the following signs and symptoms? Select all that apply.
- A. A bleeding that is concealed or apparent.
- B. Abdominal rigidity.
- C. Painful abdomen.
- D. Painless bleeding.
- E. Large placenta.
- F. Bleeding that stops spontaneously.
Correct Answer: A,B,C
Rationale: Abruptio placentae involves placental separation, causing concealed or apparent bleeding, abdominal rigidity, and pain due to uterine irritation. Painless bleeding is characteristic of placenta previa, and large placenta or spontaneous cessation are not typical.
When performing Leopold’s maneuvers on a primigravid client, the nurse is palpating the uterus as shown below. Which of the following maneuvers is the nurse performing?
- A. First maneuver
- B. Second maneuver.
- C. Third maneuver.
- D. Fourth maneuver.
Correct Answer: C
Rationale: The third Leopold’s maneuver is performed to: Identify the fetal part that is lying just above the inlet of the true pelvis (i.e., what part is presenting). It helps determine if the presenting part (usually the head or buttocks) is engaged, floating, or movable.
When preparing the room for admission of a multigravid client at 36 weeks' gestation diagnosed with severe preeclampsia, which of the following should the nurse obtain?
- A. Oxytocin infusion solution.
- B. Disposable tongue blades.
- C. Portable ultrasound machine.
- D. Padding for the side rails.
Correct Answer: D
Rationale: Padding for the side rails is necessary to prevent injury during potential seizures.
The nurse is caring for a 2-day-old neonate in the recovery room 30 minutes after surgical correction for the cardiac defect, transposition of the great vessels. Which of the following would alert the nurse to notify the physician?
- A. Oxygen saturation of 90%.
- B. Pale pink extremities.
- C. Warm, dry skin.
- D. Femoral pulse of 90 bpm.
Correct Answer: A
Rationale: An oxygen saturation of 90% is below the expected postoperative range and indicates potential hypoxemia, requiring physician notification.
A multigravid client at term is admitted to the hospital for a trial labor and possible vaginal birth. She has a history of previous cesarean delivery because of fetal distress. When the client is 4 cm dilated, she receives nalbuphine (Nubain) intravenously. While monitoring the fetal heart rate, the nurse observes minimal variability and a rate of 120 bpm. The nurse should explain the decreased variability is most likely caused by which of the following?
- A. Maternal fatigue.
- B. Fetal malposition.
- C. Small-for-gestational-age fetus.
- D. Effects of analgesic medication.
Correct Answer: D
Rationale: Nalbuphine, an opioid, can reduce fetal heart rate variability by depressing the central nervous system, a common side effect. Maternal fatigue, malposition, or small-for-gestational-age fetus are less likely causes.