Nokea
A client is to receive Pergonal (menotropins) injections for infertility prior to in-vitro fertilization. Which of the following is the expected action of this medication?
- A. Stimulation of ovulation
- B. Prolongation of the luteal phase
- C. Promotion of cervical mucus production
- D. Suppression of menstruation fertilization. Which of the following is the expected action of this medication?
Correct Answer: A
Rationale: The correct answer is A: Stimulation of ovulation. Pergonal contains menotropins, which are hormones that stimulate the ovaries to produce eggs. During in-vitro fertilization, the goal is to retrieve multiple eggs for fertilization, making ovulation stimulation crucial.
Explanation for incorrect choices:
B: Prolongation of the luteal phase - Pergonal does not affect the luteal phase, which occurs after ovulation.
C: Promotion of cervical mucus production - Pergonal does not directly influence cervical mucus production.
D: Suppression of menstruation - Pergonal does not suppress menstruation but rather induces ovulation.
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The nurse is preparing a client for cesarean delivery. What is the priority nursing action before surgery?
- A. Obtain baseline vital signs.
- B. Insert an indwelling urinary catheter.
- C. Administer prophylactic antibiotics.
- D. Verify signed informed consent.
Correct Answer: D
Rationale: The correct answer is D, verifying signed informed consent. This is the priority because it ensures the client's understanding and agreement to the procedure, respecting their autonomy. Obtaining baseline vital signs (A) is important but not the priority before surgery. Inserting a urinary catheter (B) may be needed but is not the priority over informed consent. Administering antibiotics (C) is important for preventing infection but should not take precedence over confirming the client's informed consent.
A client is admitted with a vaginal bleeding at 10 weeks' gestation and her fundal height 13cm. Which potential problem should you investigate?
- A. Hydatidiform mole
- B. DIC
- C. Previa
- D. Abruptio placenta
Correct Answer: C
Rationale: The correct answer is C: Previa. At 10 weeks' gestation, fundal height should be close to the pelvic brim, not 13cm above it. This suggests placenta previa, where the placenta implants low in the uterus, causing bleeding. Hydatidiform mole would typically present with earlier bleeding and a larger uterus. DIC and abruptio placenta are not supported by the information given at this gestational age.
A nurse in labor and delivery is caring for a client. Following delivery of the placenta, the nurse examines the umbilical cord. Which of the following vessels should the nurse expect to observe in the umbilical cord?
- A. Two veins and one artery
- B. One artery and one vein
- C. Two arteries and one veins
Correct Answer: C
Rationale: The correct answer is C: Two arteries and one vein. The umbilical cord typically contains two arteries (carrying deoxygenated blood from the fetus to the placenta) and one vein (carrying oxygenated blood from the placenta to the fetus). This is known as the "AVA" pattern. This configuration is essential for fetal circulation and oxygenation. Option A is incorrect as it has two veins and one artery, which is not the norm. Option B is also incorrect as it has one artery and one vein, missing one artery. Option D is incomplete, so it is also incorrect. Ultimately, the presence of two arteries and one vein in the umbilical cord is the correct and expected vascular arrangement for fetal circulation.
A client at 10 weeks' gestation reports frequent nausea. What dietary recommendation should the nurse provide?
- A. Avoid eating salty snacks.
- B. Drink fluids between meals.
- C. Consume three large meals a day.
- D. Avoid eating protein-rich foods.
Correct Answer: B
Rationale: The correct answer is B: Drink fluids between meals. This recommendation helps manage nausea during pregnancy by preventing dehydration, which can worsen symptoms. Consuming fluids between meals also helps maintain hydration and prevents an empty stomach, which can trigger nausea. A: Avoiding salty snacks is not directly related to managing nausea. C: Consuming three large meals a day may worsen nausea due to overeating. D: Avoiding protein-rich foods is not recommended as they are important for fetal development and overall nutrition during 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.