Nokea
A client at 34 weeks' gestation reports regular uterine contractions. What is the nurse's priority action?
- A. Encourage ambulation to relieve discomfort.
- B. Perform a sterile vaginal examination.
- C. Assess fetal heart rate and contraction pattern.
- D. Administer an analgesic as prescribed.
Correct Answer: C
Rationale: Assessing fetal heart rate and contraction pattern is crucial to evaluate for preterm labor.
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What tion in the FHR that is abrupt and appears to be does the nurse inform this group that they are at in the shape of a W. What is the most likely cause highest risk for? of this?
- A. Sexually transmitted diseases
- B. Compression of the fetal head
- C. Uterine cancer
- D. Compression of the umbilical cord
Correct Answer: D
Rationale: An abnormality in the FHR that is abrupt and appears to be in the shape of a "W" is often indicative of variable decelerations. Variable decelerations typically occur due to compression of the umbilical cord, leading to a temporary decrease in oxygen supply to the fetus. It is important for the nurse to inform this group that they are at the highest risk for compression of the umbilical cord as this can result in fetal distress and potentially lead to serious complications if not promptly addressed.
The nurse is caring for a postpartum client who is
- A. Maternal hyperglycemia 1 day postcesarean birth. What assessment data
- B. FHR, early decelerations would indicate infection? Select all that apply.
- C. FHR, late decelerations
- D. Increased pulse
Correct Answer: A
Rationale: Maternal hyperglycemia 1 day post-cesarean birth can indicate infection. Hyperglycemia can impair immune function and make the body more susceptible to infections.
During which stage of the menstrual cycle does the endometrium layer thicken?
- A. Proliferative phase
- B. Ovulation phase
- C. Luteal phase
- D. Secretory phase
Correct Answer: D
Rationale: The endometrium layer thickens during the secretory phase of the menstrual cycle. This phase occurs after ovulation and is characterized by the endometrium preparing for possible implantation of a fertilized egg by further thickening and becoming more vascularized. If pregnancy does not occur, the thickened endometrial lining will be shed during menstruation. The secretory phase is under the control of the hormone progesterone, which is produced by the corpus luteum formed in the ovary after ovulation.
The nurse is caring for a client in the postpartum period. What finding indicates a need for immediate intervention?
- A. Fundus firm and midline.
- B. Lochia rubra with large clots.
- C. Perineal pain after delivery.
- D. Slight swelling of the feet.
Correct Answer: B
Rationale: Large clots in lochia rubra may indicate retained placental fragments or postpartum hemorrhage.
The nurse is educating a male patient on how a vasectomy works. What is the best explanation for this procedure?
- A. The procedure blocks the sperm from entering into the semen and being ejaculated.
- B. The procedure removes the testicle so that sperm are not made.
- C. The tube that carries seminal fluid is blocked, causing no semen to be ejaculated.
- D. The procedure kills all sperm so they are unable to make it to the ovulated egg.
Correct Answer: A
Rationale: A vasectomy involves blocking or cutting the vas deferens to prevent sperm from being ejaculated with semen, making it an effective method of contraception. Choice B is incorrect because the testicles are not removed during a vasectomy, only the vas deferens is altered. Choice C is incorrect because seminal fluid is still produced, but sperm are prevented from entering it. Choice D is incorrect because sperm are not killed, but rather prevented from mixing with semen.