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A client at 20 weeks' gestation asks about fetal movements. What is the nurse's best response?
- A. Fetal movements are rarely felt before 24 weeks.
- B. You should feel strong, regular movements at this stage.
- C. You may feel fluttering movements, known as quickening.
- D. It is too early to feel any fetal movements.
Correct Answer: C
Rationale: The correct answer is C because quickening, described as fluttering movements, is typically felt by pregnant individuals around 18-20 weeks of gestation. This indicates fetal movement and is an important milestone in pregnancy. Choices A and D are incorrect as fetal movements can be felt as early as 18-20 weeks. Choice B is incorrect as feeling strong, regular movements is not expected until later in the pregnancy.
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How can a nurse best prevent heat loss in a newborn during the first hour of life?
- A. Place the newborn under a radiant warmer
- B. Dry the newborn and cover with a warm blanket
- C. Place the newborn in a skin-to-skin position with the mother
- D. Keep the newborn wrapped in a wet blanket
Correct Answer: A
Rationale: The correct answer is A: Place the newborn under a radiant warmer. This method is the most effective in preventing heat loss in a newborn as radiant warmers provide a consistent heat source to maintain the newborn's body temperature. This is crucial during the first hour of life when newborns are at a higher risk of hypothermia.
Choice B is not as effective as using a radiant warmer as it may not provide enough warmth to prevent heat loss. Choice C, placing the newborn in a skin-to-skin position with the mother, is beneficial for bonding and regulating the newborn's temperature in the long term but may not be as effective as a radiant warmer in the immediate post-birth period.
Choice D, keeping the newborn wrapped in a wet blanket, is incorrect as wet blankets can further contribute to heat loss through evaporative cooling. In summary, using a radiant warmer is the best option for preventing heat loss in a newborn during the critical first hour of life.
The nurse is performing a prenatal assessment. What finding is considered a positive sign of pregnancy?
- A. Positive pregnancy test.
- B. Auscultation of fetal heart tones.
- C. Hegar's sign.
- D. Chadwick's sign.
Correct Answer: B
Rationale: The correct answer is B, auscultation of fetal heart tones, because it is a definitive sign of pregnancy indicating the presence of a fetus. This can be heard around 10-12 weeks of gestation using a Doppler device. It is a positive sign as it directly confirms the existence of a developing fetus.
A: A positive pregnancy test is a probable sign and can indicate pregnancy but is not definitive.
C: Hegar's sign is a probable sign characterized by softening of the lower uterine segment, not specific to pregnancy.
D: Chadwick's sign is a probable sign of pregnancy indicated by bluish discoloration of the cervix, vagina, and labia, not a definitive sign of pregnancy.
A client is to receive Pergonal (menotropins) injections for infertility prior to in-vitro fertilization. Which of the following is the expected action of this medication?
- A. Stimulation of ovulation
- B. Prolongation of the luteal phase
- C. Promotion of cervical mucus production
- D. Suppression of menstruation fertilization. Which of the following is the expected action of this medication?
Correct Answer: A
Rationale: The correct answer is A: Stimulation of ovulation. Pergonal contains menotropins, which are hormones that stimulate the ovaries to produce eggs. During in-vitro fertilization, the goal is to retrieve multiple eggs for fertilization, making ovulation stimulation crucial.
Explanation for incorrect choices:
B: Prolongation of the luteal phase - Pergonal does not affect the luteal phase, which occurs after ovulation.
C: Promotion of cervical mucus production - Pergonal does not directly influence cervical mucus production.
D: Suppression of menstruation - Pergonal does not suppress menstruation but rather induces ovulation.
A postpartum client calls the pediatric clinic to report that her 4-day old female newborn has a spot of blood on her diaper. Which of the following statements made by the nurse is most appropriate?
- A. Your newborn may have a urinary infection, continue to breastfeed frequently
- B. Your newborn has jaundice so it may need phototherapy
- C. This is a normal finding due to withdrawal of maternal hormones
- D. Your baby has an immature immune system, continue to breastfeed frequently
Correct Answer: C
Rationale: The correct answer is C because the spot of blood on the diaper of a 4-day old female newborn is a normal finding due to the withdrawal of maternal hormones. During pregnancy, the baby is exposed to maternal hormones, and after birth, the sudden decrease in these hormones can cause a temporary withdrawal bleeding. This is known as pseudomenstruation and is common in newborn girls. It is important for the nurse to reassure the mother that this is a normal and harmless occurrence.
Choice A is incorrect because urinary infection is not typically the cause of blood on the diaper in a newborn. Choice B is incorrect because jaundice does not typically present with blood in the diaper. Choice D is incorrect because while breastfeeding is important for the baby's immune system, it is not directly related to the presence of blood on the diaper in this case.
Many teens wait until the second or even third trimester to seek prenatal care. The nurse should understand that the reasons behind this delay include which of the following? (Select all that apply.)
- A. Continuing to deny the pregnancy
- B. Uncertainty about where to go for care
- C. Lack of realization that they are pregnant
- D. A desire to gain control over their situation
Correct Answer: A
Rationale: The correct answer is A: Continuing to deny the pregnancy. This is because some teens may struggle to come to terms with their pregnancy and deny it, leading to delays in seeking prenatal care. The other choices are incorrect. B: Uncertainty about where to go for care is not a common reason for delaying prenatal care as resources and information are usually available. C: Lack of realization that they are pregnant is unlikely as most teens eventually become aware of their pregnancy. D: A desire to gain control over their situation does not usually lead to delaying prenatal care as seeking care is a proactive step towards gaining control.