Nokea
A client at 36 weeks' gestation reports frequent urination and lower back pain. What should the nurse assess for?
- A. Preterm labor.
- B. Urinary tract infection.
- C. Normal third-trimester changes.
- D. Preeclampsia.
Correct Answer: A
Rationale: Frequent urination and back pain at 36 weeks may indicate preterm labor and require further assessment.
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What is the primary purpose of administering vitamin K to a newborn?
- A. Prevent anemia
- B. Enhance immune function
- C. Prevent bleeding disorders
- D. Promote growth and development
Correct Answer: C
Rationale: Newborns are born with low levels of vitamin K, essential for blood clotting.
The nurse is teaching a prenatal class about labor. What statement indicates understanding?
- A. True labor contractions are irregular and stop with rest.
- B. False labor contractions cause cervical dilation.
- C. True labor contractions increase in intensity and frequency.
- D. False labor contractions are felt in the back.
Correct Answer: C
Rationale: True labor contractions become progressively stronger and lead to cervical dilation and effacement.
Which finding in a 36-week pregnant client is most concerning?
- A. Braxton Hicks contractions
- B. Frequent urination
- C. Proteinuria of +2
- D. Weight gain of 2 pounds in a week
Correct Answer: C
Rationale: Proteinuria is a sign of preeclampsia, requiring immediate assessment.
A nurse teaches newly pregnant clients that if an ovum is fertilized and implants in the endometrium, the hormone the fertilized egg begins to secrete is which of the following?
- A. Estrogen
- B. Human chorionic gonadotropin (hCG)
- C. Progesterone
- D. Luteinizing hormone
Correct Answer: B
Rationale: hCG is a hormone secreted by the fertilized egg shortly after implantation. It signals the body to maintain the corpus luteum, which produces progesterone essential for sustaining the early stages of pregnancy.
A nurse is caring for a client who is in the first stage of labor. The nurse observes the umbilical cord protruding from the vagina. Which of the following actions should the nurse perform first?
- A. Cover the cord with a sterile, moist saline dressing.
- B. Prepare the client for an immediate birth.
- C. Place the client in knee-chest position.
- D. Insert a gloved hand into the vagina to relieve pressure on the cord. Rationale: This is the first nursing action because it is essential to prevent any pressure on the umbilical cord to promote oxygenation of the fetus.
Correct Answer: D
Rationale: The correct action for the nurse to perform first when observing the umbilical cord protruding from the vagina during the first stage of labor is to insert a gloved hand into the vagina to relieve pressure on the cord. This is crucial to prevent compression of the cord, which could compromise oxygenation to the fetus. By gently lifting the presenting part off the cord, the nurse can help maintain blood flow and prevent fetal distress. Once the pressure on the cord is relieved, additional interventions such as preparing the client for immediate birth, covering the cord with a sterile, moist saline dressing, or positioning the client in knee-chest position may be necessary depending on the clinical situation. But the priority is to relieve pressure on the umbilical cord promptly to ensure the well-being of the fetus.