Nokea
A client at 28 weeks' gestation reports regular uterine contractions. What is the nurse's priority intervention?
- A. Administer tocolytic medication.
- B. Perform a sterile vaginal examination.
- C. Assess fetal heart rate and contraction pattern.
- D. Encourage ambulation to relieve discomfort.
Correct Answer: C
Rationale: Assessing fetal heart rate and contraction patterns is critical to evaluate the risk of preterm labor.
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Which order should the nurse implement first?
- A. Give 1L LR IV (VS indicate hypovolemia from dehydration,
- B. LR will reestablish vascular volume and bring BP up)
- C. Weigh the client
- D. Administer Maalox orally
Correct Answer: A
Rationale: The correct order of implementation in this scenario should focus on addressing the immediate physiological needs of the patient. The vital signs indicating hypovolemia from dehydration require prompt action to stabilize the patient's condition. Giving 1L of LR IV will help reestablish vascular volume, improve blood pressure, and address the underlying issue of dehydration. By addressing the hypovolemia first, the nurse can effectively start the process of stabilizing the patient before moving on to other interventions such as weighing the client, administering Maalox orally, or encouraging liquid intake.
The nurse is monitoring a pregnant client with severe preeclampsia. Which finding requires immediate intervention?
- A. Blood pressure of 140/90 mmHg.
- B. Urine output of 30 mL/hr.
- C. Complaints of headache and blurred vision.
- D. Weight gain of 1 pound in one week.
Correct Answer: C
Rationale: Headache and blurred vision are signs of worsening preeclampsia, indicating potential eclampsia.
A pregnant client tells the clinic nurse she wants to know the sex of her baby as soon as it can be determined. What factor allows this at 12 weeks' gestation?
- A. The appearance of the fetal external genitalia
- B. The beginning of differentiation in the fetal groin
- C. The fetal testes are descended into the scrotal sac
- D. The internal differences in males and females become apparent
Correct Answer: A
Rationale: By 12 weeks, the external genitalia are sufficiently developed for visual determination of the baby's sex.
Pregnant Black people have more complications resulting from epigenetic changes caused by prolonged stress due to racism and discrimination. What complication could arise because of this history?
- A. postterm pregnancy
- B. preeclampsia
- C. liver disease
- D. cholestasis of pregnancy
Correct Answer: B
Rationale: Prolonged stress and systemic racism contribute to higher rates of preeclampsia in Black pregnant individuals.
A pregnant woman tells the nurse-midwife, 'I've heard that if I eat certain foods during my pregnancy, the baby will be a boy.' The nurse-midwife should explain that this is a myth, and that the sex of the baby is determined at what time?
- A. At the time of ejaculation
- B. At the time of fertilization
- C. At the time of implantation
- D. At the time of differentiation
Correct Answer: B
Rationale: The sex of a baby is determined at fertilization. Sperm cells carry either an X or Y chromosome, while the ovum only carries an X chromosome. If the sperm contributes an X chromosome, the baby will be female, and if it contributes a Y chromosome, the baby will be male.