Nokea
A client in labor reports sudden pain and bright red vaginal bleeding. What should the nurse suspect?
- A. Placenta previa.
- B. Abruptio placentae.
- C. Preterm labor.
- D. Rupture of membranes.
Correct Answer: B
Rationale: Bright red bleeding and sudden pain suggest abruptio placentae, requiring urgent intervention.
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The patient came for an induction and under which circumstances does the nurse remove prostaglandin from the patient's cervix? SATA
- A. N&V
- B. Late deceleration
- C. Contractions every 90 seconds
- D. Contractions every 5 minutes
Correct Answer: B
Rationale: A. Nausea and vomiting (N&V) are not typically indications for removing prostaglandin from the patient's cervix during induction. These symptoms are common side effects and can be managed without removing the prostaglandin.
The nurse is monitoring a client who is 34 weeks ges- dividing?
- A. Trophoblast or inner cell mass that becomes the fetal monitor tracing are a priority for the nurse to placenta
- B. Embryoblast or inner cell mass that becomes the that apply. embryo
- C. Baseline FHR 140, accelerations, late decelerations,
- D. Morula
Correct Answer: A
Rationale: In the context of the question, the nurse is monitoring a 34-week gestation client. At 34 weeks, the trophoblast or inner cell mass has already developed into the placenta, which is formed earlier in pregnancy. Therefore, choice A is the most relevant option in this scenario. Trophoblast is critical for implantation and the formation of the placenta, which plays a vital role in supporting the developing fetus by providing oxygen and nutrients. Understanding the different stages of fetal development can help the nurse provide optimal care and monitor for any potential issues that may arise during pregnancy.
A client in the third trimester reports severe itching without rash. What condition should the nurse suspect?
- A. Cholestasis of pregnancy.
- B. Preeclampsia.
- C. Gestational diabetes.
- D. Fungal infection.
Correct Answer: A
Rationale: Severe itching in pregnancy without a rash is commonly associated with cholestasis of pregnancy.
The nurse is teaching a client with preeclampsia about home care. Which statement indicates understanding?
- A. I should monitor my blood pressure once a week.
- B. I should limit my fluid intake to reduce swelling.
- C. I will report any headache or vision changes immediately.
- D. I can exercise daily to maintain health.
Correct Answer: C
Rationale: Headache and vision changes can signal worsening preeclampsia, requiring prompt medical attention.
An African American woman noticed bruises on a newborn girl's buttocks, and she asks the nurse who spanked the baby? The nurse responds
- A. Mongolian spots
- B. Ecchymosis
- C. Birth trauma
- D. Petechiae
Correct Answer: A
Rationale: Mongolian spots are a common benign skin condition in newborn babies, especially those with darker skin tones, such as African American babies. These spots appear as blue or purple bruises or patches, typically on the lower back and buttocks, and can easily be mistaken for bruises caused by physical harm. It is important for healthcare providers and caregivers to be aware of Mongolian spots to avoid confusion with signs of abuse. In this case, the nurse is likely explaining that the bruises on the newborn girl's buttocks are due to Mongolian spots, not being spanked.