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A client in the second stage of labor reports intense rectal pressure. What does this finding indicate?
- A. The baby is in a breech position.
- B. Cervical dilation is incomplete.
- C. The baby is descending into the birth canal.
- D. Labor contractions are ineffective.
Correct Answer: C
Rationale: Step 1: In the second stage of labor, the baby is descending into the birth canal for delivery.
Step 2: Intense rectal pressure is a common sensation as the baby moves down.
Step 3: This indicates progress in labor as the baby is descending.
Step 4: Choice A is incorrect as breech position presents differently.
Step 5: Choice B is incorrect as incomplete cervical dilation may not cause rectal pressure.
Step 6: Choice D is incorrect as effective labor contractions are needed for descent.
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A nurse is teaching the parents of a newborn how to care for their child's uncircumcised penis. Which of the following instructions should the nurse include?
- A. Retract the foreskin until you feel resistance.
- B. Use a cotton swab to clean under the foreskin.
- C. Apply petroleum jelly to the foreskin.
- D. Wash the penis once per day with soup and water.
Correct Answer: D
Rationale: The correct answer is D because washing the penis once per day with soap and water is the appropriate way to care for an uncircumcised penis. This helps maintain good hygiene and prevents infections. Retracting the foreskin forcefully (Choice A) can cause injury and should not be done until the child is older. Using a cotton swab (Choice B) can leave fibers behind and may cause irritation. Applying petroleum jelly (Choice C) is unnecessary and can increase the risk of infections. Therefore, washing the penis with soap and water daily is the most effective and safe method for caring for an uncircumcised penis.
A client at 34 weeks' gestation reports decreased fetal movements. What should the nurse advise first?
- A. Drink a glass of juice and lie down.
- B. Come to the clinic immediately.
- C. Monitor fetal movements for 24 hours.
- D. Call the healthcare provider tomorrow.
Correct Answer: A
Rationale: The correct answer is A: Drink a glass of juice and lie down. This advice is based on the concept that consuming juice can stimulate fetal movements due to the increase in blood sugar levels. Lying down also helps the client focus on feeling the movements. This initial step is non-invasive and can potentially address the decreased fetal movements promptly. Choices B and D delay action, which can be dangerous if there is a significant issue with the baby. Choice C might lead to unnecessary waiting and potential risks if the fetus is in distress.
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.
A nurse is receiving laboratory results for a term newborn who is 24 hr. old. Which of the following results require intervention by the nurse?
- A. WBC count 10,000/mm3
- B. Platelets 180,000/mm3
- C. Hemoglobin 20g/dL
- D. Glucose 20 mg/dL
Correct Answer: D
Rationale: The correct answer is D because a glucose level of 20 mg/dL in a term newborn is significantly low and requires immediate intervention by the nurse. Low glucose levels can lead to hypoglycemia, which can be harmful to the newborn's brain development and overall health. A WBC count of 10,000/mm3 is within normal range for a newborn. Platelets of 180,000/mm3 and hemoglobin of 20g/dL are also within normal limits for a term newborn and do not require intervention.
What is a statement that best describes reproductive health?
- A. Reproductive health focuses solely on the ability to reproduce and have children.
- B. Reproductive health encompasses physical well-being but does not include mental and social aspects.
- C. Reproductive health involves complete physical, mental, and social well-being related to the reproductive system.
- D. Reproductive health is limited to making informed decisions about contraception methods.
Correct Answer: C
Rationale: The correct answer is C because reproductive health is not just about the ability to reproduce but also includes mental and social well-being. This choice aligns with the World Health Organization's definition of reproductive health, which emphasizes holistic well-being. Choice A is incorrect as it oversimplifies reproductive health. Choice B is incorrect because reproductive health should address all aspects of well-being. Choice D is incorrect as reproductive health goes beyond just contraception to encompass a broader scope of health and well-being.