Nokea
A client is in the first trimester of pregnancy and lacks immunity to rubella. When should the client receive rubella immunization?
- A. Shortly after giving birth
- B. In the third trimester
- C. Immediately
- D. During the next attempt to get pregnant
Correct Answer: A
Rationale: The correct answer is A. Rubella immunization should be given shortly after giving birth to prevent any potential harm to the fetus during pregnancy. Immunization during pregnancy is contraindicated to avoid any risk of harm to the developing baby. Option B is incorrect as immunization in the third trimester can still pose a risk to the fetus. Option C is incorrect as immediate immunization during pregnancy is not recommended. Option D is incorrect as waiting until the next attempt to get pregnant does not protect the current fetus.
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A nurse is caring for several clients. The nurse should recognize that it is safe to administer tocolytic therapy to which of the following clients?
- A. A client who is experiencing fetal death at 32 weeks of gestation
- B. A client who is experiencing preterm labor at 26 weeks of gestation
- C. A client who is experiencing Braxton-Hicks contractions at 36 weeks of gestation
- D. A client who has a post-term pregnancy at 42 weeks of gestation
Correct Answer: B
Rationale: Correct Answer: B
Rationale:
1. Tocolytic therapy is used to delay preterm labor and prevent premature birth.
2. Administering tocolytic therapy at 26 weeks of gestation allows time for corticosteroids to enhance fetal lung maturity.
3. Delaying labor at this stage can improve neonatal outcomes.
4. Other choices are incorrect because tocolytic therapy is not indicated for fetal death, Braxton-Hicks contractions, or post-term pregnancy.
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.
A healthcare professional in the emergency department is caring for a client who presents with severe abdominal pain in the left lower quadrant. The provider suspects a ruptured ectopic pregnancy. Which of the following signs indicates to the healthcare professional that the client has blood in the peritoneum?
- A. Chvostek's sign
- B. Cullen's sign
- C. Chadwick's sign
- D. Goodell's sign
Correct Answer: B
Rationale: The correct answer is B: Cullen's sign. Cullen's sign is the presence of periumbilical ecchymosis, indicating blood in the peritoneum due to internal bleeding from a ruptured ectopic pregnancy. Chvostek's sign (choice A) is related to facial muscle spasm due to hypocalcemia. Chadwick's sign (choice C) is bluish discoloration of the cervix indicating pregnancy. Goodell's sign (choice D) is softening of the cervix in early pregnancy. These signs are not indicative of blood in the peritoneum like Cullen's sign is.
When monitoring uterine contractions in a client in the active phase of the first stage of labor, which finding should the nurse report to the provider?
- A. Contractions lasting longer than 90 seconds
- B. Contractions occurring every 3 to 5 minutes
- C. Contractions are strong in intensity
- D. Client reports feeling contractions in the lower back
Correct Answer: A
Rationale: Rationale: Contractions lasting longer than 90 seconds can indicate uterine hyperstimulation, which can lead to decreased oxygenation of the fetus. This finding should be reported to the provider for further assessment and intervention. Contractions occurring every 3 to 5 minutes (choice B) are normal in the active phase of labor. Strong contractions (choice C) are also expected during this phase. Feeling contractions in the lower back (choice D) is common and not typically a cause for concern. Reporting contractions lasting longer than 90 seconds is crucial to ensure the safety of both the mother and the baby.
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.