Nokea
A client who delivered a healthy newborn an hour ago asked the nurse when she can go home. Which information is most important for the nurse to provide the client?
- A. After the baby no longer demonstrates acrocyanosis
- B. After the baby receives the vitamin K injection
- C. When ambulating to avoid causing dizziness
- D. When there is no significant vaginal bleeding
Correct Answer: D
Rationale: The most critical information for the nurse to provide the client is ensuring that there is no significant vaginal bleeding before discharge. This is vital to prevent complications such as postpartum hemorrhage. Options A, B, and C are important aspects of postpartum care, but assessing and managing vaginal bleeding takes precedence due to its potential seriousness.
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A nurse on a labor and delivery unit is providing teaching to a client who plans to use hypnosis to control labor pain. Which of the following information should the nurse include?
- A. Focusing on controlling body functions
- B. Synchronized breathing is often helpful during hypnosis
- C. Hypnosis can be beneficial if practiced during the prenatal period
- D. Hypnosis is ineffective for controlling pain associated with labor
Correct Answer: C
Rationale: Hypnosis can be an effective method of pain control during labor, especially if practiced during the prenatal period. Choice A is not specific to hypnosis and may not be directly related. Choice B is not essential for hypnosis and may not always be required. Choice D is incorrect as hypnosis has been shown to be beneficial for managing labor pain when done correctly, making it an inappropriate option to include in the teaching.
A charge nurse is teaching a group of staff nurses about fetal monitoring during labor. Which of the following findings should the charge nurse instruct the staff members to report to the provider?
- A. Contraction durations of 95 to 100 seconds
- B. Contraction frequency of 2 to 3 minutes apart
- C. Absent early deceleration of fetal heart rate
- D. Fetal heart rate is 140/min
Correct Answer: A
Rationale: The correct answer is A. Contraction durations of 95 to 100 seconds are prolonged, indicating uterine hyperstimulation, which can lead to fetal distress and requires immediate intervention. Reporting this finding to the provider is crucial to ensure timely management and prevent adverse outcomes. Choice B, contraction frequency of 2 to 3 minutes apart, is within the normal range and does not raise immediate concerns. Choice C, absent early deceleration of fetal heart rate, is a reassuring finding suggesting fetal well-being. Choice D, a fetal heart rate of 140/min, is also normal for a fetus and does not typically require immediate reporting unless it deviates significantly from the baseline or is accompanied by other concerning signs.
A healthcare professional is caring for a client who is 14 weeks of gestation. At which of the following locations should the healthcare professional place the Doppler device when assessing the fetal heart rate?
- A. Midline 2 to 3 cm (0.8 to 1.2 in) above the symphysis pubis
- B. Left Upper Abdomen
- C. Two fingerbreadths above the umbilicus
- D. Lateral at the Xiphoid Process
Correct Answer: A
Rationale: At 14 weeks of gestation, the uterus is still relatively low in the abdomen. Placing the Doppler midline 2 to 3 cm above the symphysis pubis is appropriate for assessing the fetal heart rate. This location allows for better detection of the fetal heart tones as the uterus is at a lower position during this stage of pregnancy. Placing the Doppler on the left upper abdomen would not be ideal at 14 weeks gestation as the uterus is not yet at that level. Placing it two fingerbreadths above the umbilicus or lateral at the xiphoid process would also not be accurate for locating the fetal heart rate at this stage of gestation.
_____ is a life-threatening disease, characterized by high blood pressure that may afflict women late in the second or early in the third trimester.
- A. Rubella
- B. Syphilis
- C. Preeclampsia
- D. Phenylketonuria
Correct Answer: C
Rationale: Preeclampsia is a serious pregnancy complication characterized by high blood pressure that typically occurs in the second half of pregnancy. If left untreated, it can lead to severe complications for both the mother and the baby. Rubella (choice A) is a viral infection that can harm the developing fetus but is not directly related to high blood pressure in pregnancy. Syphilis (choice B) is a sexually transmitted infection that can affect pregnancy but does not specifically cause high blood pressure. Phenylketonuria (choice D) is a genetic disorder that affects metabolism and is not associated with high blood pressure in pregnancy.
A newborn is being assessed following a forceps-assisted birth. Which of the following clinical manifestations should the nurse identify as a complication of the birth method?
- A. Hypoglycemia
- B. Polycythemia
- C. Facial Palsy
- D. Bronchopulmonary dysplasia
Correct Answer: C
Rationale: Facial palsy is a known complication of forceps-assisted birth. During forceps delivery, pressure applied to the facial nerve can result in facial palsy. The newborn may present with weakness or paralysis of the facial muscles on one side. Hypoglycemia (Choice A) is not directly related to forceps-assisted birth. Polycythemia (Choice B) is a condition characterized by an increased number of red blood cells and is not typically associated with forceps delivery. Bronchopulmonary dysplasia (Choice D) is a lung condition that primarily affects premature infants who require mechanical ventilation and prolonged oxygen therapy, not a direct outcome of forceps-assisted birth.