Nokea
A client is hospitalized in the acute phase of severe ovarian hyperstimulation syndrome. The following nursing diagnosis has been identified: Fluid volume excess (extravascular) related to third spacing. Which of the following nursing goals is highest priority in relation to this diagnosis?
- A. Client's weight will be within normal limits by date of discharge.
- B. Client's skin will show no evidence of breakdown throughout hospitalization.
- C. Client's electrolyte levels will be within normal limits within one day.
- D. Client's lung fields will remain clear throughout hospitalization.
Correct Answer: D
Rationale: Respiratory compromise is a critical concern in severe ovarian hyperstimulation syndrome.
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What is the significance of luteal phase deficiency in infertility?
- A. It results from inadequate estrogen levels during ovulation.
- B. It is caused by insufficient progesterone to maintain the uterine lining.
- C. It occurs only in women with polycystic ovary syndrome (PCOS).
- D. It leads to the release of immature eggs.
Correct Answer: B
Rationale: The correct answer is B because luteal phase deficiency is caused by insufficient progesterone to maintain the uterine lining, which is crucial for implantation of a fertilized egg. This deficiency can lead to difficulty in sustaining a pregnancy.
A is incorrect because estrogen levels are more related to follicular phase than luteal phase.
C is incorrect because luteal phase deficiency can occur in women without PCOS.
D is incorrect because immature eggs are more related to ovulation issues rather than luteal phase deficiency.
A nurse is assessing a woman in labor. Which finding would the nurse identify as a cause for concern during a contraction?
- A. heart rate increase from 76 bpm to 90 bpm
- B. blood pressure rise from 110/60 mm Hg to 120/74
- C. white blood cell count of 12,000 cells/mm3
- D. N/A
Correct Answer: D
Rationale: The correct answer is D because none of the given choices are typically a cause for concern during a contraction. If any of the choices were related to fetal distress or abnormal fetal heart rate patterns, they would be concerning.
A 44-year-old woman presents with an unexpected pregnancy. She asks the nurse, 'Is my baby going to have a birth defect? My third cousin has Down syndrome.' What is the nurse's best response?
- A. Tell the patient she is at risk for gene mutation because a birth defect in a distant relative places the woman at increased risk.
- B. Discuss the potential risk for intrauterine growth retardation due to the mother's advanced age.
- C. Discuss the patient's situation with the physician to ask for a referral to high-risk obstetrics.
- D. Discuss the potential risk for a chromosomal abnormality based on the patient's advanced age.
Correct Answer: D
Rationale: Step 1: The correct answer is D because advanced maternal age (AMA), generally defined as 35 years or older, is a well-known risk factor for chromosomal abnormalities, such as Down syndrome.
Step 2: Down syndrome is more common in babies born to mothers over the age of 35 due to the increased likelihood of errors in cell division during egg development.
Step 3: Given the patient's age of 44, she falls into the category of AMA and is at an increased risk for chromosomal abnormalities in her baby.
Step 4: Option A is incorrect as the risk is not solely based on gene mutation but rather on the increased chance of chromosomal abnormalities due to age.
Step 5: Option B is incorrect as it focuses on intrauterine growth retardation, which is not directly related to the patient's query about birth defects.
Step 6: Option C is incorrect as a referral to high-risk obstetrics may not be necessary solely based on the patient's
What is the purpose of progesterone in supporting early pregnancy?
- A. To increase fetal growth rates.
- B. To maintain the uterine lining and prevent menstrual shedding.
- C. To stimulate ovulation during the menstrual cycle.
- D. To regulate the release of other reproductive hormones.
Correct Answer: B
Rationale: The correct answer is B because progesterone plays a crucial role in maintaining the uterine lining to support implantation and prevent menstrual shedding. Progesterone prepares the uterus for the potential implantation of a fertilized egg by thickening the endometrium. If fertilization occurs, progesterone continues to support the pregnancy by ensuring the uterine lining remains intact to provide a nurturing environment for the developing embryo. Choices A, C, and D are incorrect because progesterone's main function in early pregnancy is not to increase fetal growth rates, stimulate ovulation, or regulate the release of other reproductive hormones.
A patient undergoing ovarian stimulation asks about the purpose of frequent ultrasounds. What should the nurse explain?
- A. Ultrasounds monitor embryo development after transfer.
- B. They assess the growth and development of ovarian follicles.
- C. They confirm ovulation has occurred naturally.
- D. Ultrasounds are used to visualize uterine contractions.
Correct Answer: B
Rationale: The correct answer is B because frequent ultrasounds are used to monitor the growth and development of ovarian follicles during ovarian stimulation. This is essential to ensure proper timing for ovulation induction or egg retrieval. Ultrasounds do not monitor embryo development after transfer (choice A), confirm natural ovulation (choice C), or visualize uterine contractions (choice D) in this context.