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A client is being educated by a healthcare provider about the changes she should expect when planning to become pregnant. Identify the correct sequence of maternal changes. A. Amenorrhea B.Lightening C. Goodell's sign D. Quickening
- A. A,B,C,D
- B. D,B,A,C
- C. A,D,B,C
- D. A,C,D,B
Correct Answer: D
Rationale: The correct sequence of maternal changes when planning to become pregnant is A) Amenorrhea, C) Goodell's sign, D) Quickening, and B) Lightening. Amenorrhea is the absence of menstruation, indicating possible pregnancy. Goodell's sign is the softening of the cervix and vagina. Quickening is the first fetal movements felt by the mother. Lightening occurs as the baby drops lower into the pelvis. This sequence reflects the chronological order of physiological changes during pregnancy. Choices A, B, and C do not follow the correct sequence of maternal changes as outlined in pregnancy progression.
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A client at 38 weeks of gestation with a diagnosis of preeclampsia has the following findings. Which of the following should the nurse identify as inconsistent with preeclampsia?
- A. 1+ pitting sacral edema
- B. 3+ protein in the urine
- C. Blood pressure 148/98 mm Hg
- D. Deep tendon reflexes of +1
Correct Answer: D
Rationale: The correct answer is D, Deep tendon reflexes of +1. In preeclampsia, deep tendon reflexes are typically hyperactive, not diminished (+1). This indicates hyporeflexia, which is inconsistent with preeclampsia. A is consistent with preeclampsia, as mild edema is common. B is also consistent, as proteinuria is a hallmark sign. C is consistent, as elevated blood pressure is a key feature. Therefore, D is the only choice that does not align with the expected findings in preeclampsia.
A healthcare provider is preparing to administer vitamin K by IM injection to a newborn. The medication should be administered into which of the following muscles?
- A. Vastus lateralis
- B. Ventrogluteal
- C. Dorsogluteal
- D. Deltoid
Correct Answer: A
Rationale: The correct answer is A: Vastus lateralis. This muscle is the preferred site for IM injections in newborns due to its large muscle mass and minimal risk of damage to nerves and blood vessels. Administering vitamin K in the vastus lateralis ensures proper absorption and distribution of the medication. Ventrogluteal and dorsogluteal sites are not recommended for newborns due to the risk of sciatic nerve damage and limited muscle mass. The deltoid muscle is typically used for older children and adults, not newborns.
A patient on the labor and delivery unit is having induction of labor with oxytocin administered through a secondary IV line. Uterine contractions occur every 2 minutes, last 90 seconds, and are strong to palpation. The baseline fetal heart rate is 150/min, with uniform decelerations beginning at the peak of the contraction and a return to baseline after the contraction is over. Which of the following actions should the nurse take?
- A. Decrease the rate of infusion of the maintenance IV solution.
- B. Discontinue the infusion of the IV oxytocin.
- C. Increase the rate of infusion of the IV oxytocin.
- D. Slow the client's breathing rate.
Correct Answer: B
Rationale: The correct answer is B: Discontinue the infusion of the IV oxytocin. Decelerations starting at the peak of contractions indicate uteroplacental insufficiency, which can be caused by hyperstimulation from oxytocin. Stopping the oxytocin infusion will help alleviate this issue and improve fetal oxygenation. Choice A would not address the underlying cause of the decelerations. Choice C would worsen the hyperstimulation. Choice D is not directly related to the fetal heart rate decelerations.
While caring for a newborn, a nurse auscultates an apical heart rate of 130/min. Which of the following actions should the nurse take?
- A. Ask another nurse to verify the heart rate.
- B. Document this as an expected finding.
- C. Call the provider to further assess the newborn.
- D. Prepare the newborn for transport to the NICU.
Correct Answer: B
Rationale: The correct answer is B: Document this as an expected finding. A heart rate of 130/min in a newborn is within the normal range (120-160/min). The nurse should document this as an expected finding because it indicates a healthy heart rate for a newborn. There is no immediate need for intervention or further assessment as the heart rate falls within the normal range for a newborn. Asking another nurse to verify the heart rate (choice A) is unnecessary as it is within the normal range. Calling the provider to further assess the newborn (choice C) is not needed since the heart rate is normal. Preparing the newborn for transport to the NICU (choice D) is not indicated as the heart rate is within the normal range.
During an assessment of a newborn following a vacuum-assisted delivery, which of the following findings should the healthcare provider be informed about?
- A. Poor sucking
- B. Blue discoloration of the hands and feet
- C. Soft, edematous area on the scalp
- D. Facial edema
Correct Answer: A
Rationale: The correct answer is A: Poor sucking. This finding is concerning as it may indicate potential issues with feeding and nutrition in the newborn, which can lead to complications. Poor sucking can be a sign of various underlying problems that require prompt intervention. Blue discoloration of the hands and feet (choice B) is likely due to peripheral cyanosis, which is common in newborns and often resolves on its own. Soft, edematous area on the scalp (choice C) is a common finding in newborns after vacuum-assisted delivery and typically resolves without intervention. Facial edema (choice D) is also a common finding in newborns after delivery and typically resolves on its own.