Nokea
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.
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A pregnant woman is scheduled to undergo chorionic villus sampling (CVS) based on genetic family history. Which medication does the nurse anticipate will be administered?
- A. Magnesium sulfate
- B. Prostaglandin suppository
- C. RhoGAM if the patient is Rh-negative
- D. Betamethasone
Correct Answer: C
Rationale: The correct answer is C: RhoGAM if the patient is Rh-negative. During CVS, there is a risk of maternal-fetal blood mixing, especially if the patient is Rh-negative. RhoGAM is given to prevent sensitization to the Rh factor, which could lead to hemolytic disease in the newborn. Magnesium sulfate (A) is not indicated for CVS. Prostaglandin suppository (B) is used for cervical ripening or induction of labor, not for CVS. Betamethasone (D) is a corticosteroid given to pregnant women at risk of preterm delivery to promote fetal lung maturation, not indicated for CVS.
A breastfeeding client, 6 days postdelivery, calls the postpartum unit stating, “I think I am engorged. My breasts are very hard and hot and they really hurt.” Which of the following questions should the nurse ask at this time?
- A. “Have you taken a warm shower this morning?”
- B. “Do you have an electric breast pump?”
- C. “How much did you have to drink yesterday?”
- D. “When was the last time you fed the baby?”
Correct Answer: D
Rationale: Asking when the client last fed the baby helps determine if engorgement is due to infrequent feeding, which is a common cause of breast engorgement.
A nurse should monitor a client who is postpartum from a forceps delivery for which of the following complications?
- A. Placental abruption.
- B. Seizure.
- C. Idiopathic thrombocytopenia.
- D. Infection.
Correct Answer: D
Rationale: Forceps delivery increases the risk of trauma and infection due to potential tissue damage.
A patient, gravida 2, para 1, comes for a prenatal visit at 20 weeks of gestation. Her fundus is palpated 3 cm below the umbilicus. This finding is
- A. appropriate for gestational age.
- B. a sign of impending complications.
- C. lower than normal for gestational age.
- D. higher than normal for gestational age.
Correct Answer: C
Rationale: The fundal height at 20 weeks gestation should be at the level of the umbilicus. When it is palpated 3 cm below the umbilicus, it is considered lower than normal for gestational age. This finding suggests possible fetal growth restriction or incorrect dating of the pregnancy. It is crucial to monitor closely for fetal well-being and growth.
Choice A is incorrect because being 3 cm below the umbilicus is not appropriate for gestational age. Choice B is incorrect as it does not necessarily indicate impending complications, but rather a need for further evaluation. Choice D is incorrect as a fundus higher than normal for gestational age would suggest a larger-than-expected fetus or multiple gestation.
A nurse notes that a baby is lying in a crib in the tonic neck position. In which of the following positions is the baby lying?
- A. One of the baby's arms and one of its legs are extended to the same side the baby's head is facing.
- B. When the baby faces straight ahead, the baby's head tilts toward one side.
- C. Both the baby's back and head are sharply arched backward and resist being moved to midline.
- D. When the baby lies prone, the baby's body arches to one side.
Correct Answer: A
Rationale: The tonic neck reflex, or fencer's position, involves the baby's arm and leg on one side extending while the opposite arm and leg flex.