Nokea
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.
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A nurse in a prenatal clinic overhears a newly licensed nurse discussing conception with a client. Which of the following statements by the newly licensed nurse requires intervention by the nurse?
- A. Fertilization takes place in the outer third of the fallopian tube.
- B. Implantation occurs between 6 to 10 days after conception.
- C. Sperm remain viable in the woman's reproductive tract for 2 to 3 days.
- D. Bleeding or spotting can accompany implantation.
Correct Answer: B
Rationale: The correct answer is B because implantation actually occurs around 6-10 days after fertilization, not after conception. This is a critical distinction as conception refers to the union of sperm and egg to form a zygote, while fertilization specifically refers to the fusion of the genetic material. Therefore, the statement by the newly licensed nurse is inaccurate and requires intervention.
A: Fertilization typically occurs in the outer third of the fallopian tube, making this statement correct.
C: Sperm can indeed remain viable in the woman's reproductive tract for 2 to 3 days, indicating this statement is accurate.
D: Bleeding or spotting can indeed accompany implantation, making this statement correct.
In summary, choice B is incorrect because implantation occurs around 6-10 days after fertilization, not conception. Choices A, C, and D are all correct statements related to conception and fertilization.
A client reports unrelieved episiotomy pain 8 hours following a vaginal birth. Which of the following actions should the nurse take?
- A. Apply an ice pack to the affected area.
- B. Offer a warm sitz bath.
- C. Provide a squeeze bottle of antiseptic solution.
- D. Place a hot pack on the perineum.
Correct Answer: A
Rationale: The correct answer is A: Apply an ice pack to the affected area. Ice helps reduce inflammation and numb the pain, providing relief for the client. Step 1: Ice constricts blood vessels, reducing swelling and pain. Step 2: Ice numbs the area, providing immediate relief. Step 3: Ice is recommended for acute pain management. Summary: B (warm sitz bath) may increase blood flow and exacerbate swelling. C (antiseptic solution) is not indicated for pain relief. D (hot pack) may worsen inflammation and pain.
A client who is postpartum received methylergonovine. Which of the following findings indicates that the medication was effective?
- A. Increase in blood pressure
- B. Fundus firm to palpation
- C. Increase in lochia
- D. Report of absent breast pain
Correct Answer: B
Rationale: The correct answer is B: Fundus firm to palpation. Methylergonovine is a medication used to promote uterine contraction, which helps the uterus return to its pre-pregnancy size and prevent postpartum hemorrhage. When the fundus is firm to palpation, it indicates that the uterus is contracting effectively, which is the desired outcome of giving methylergonovine.
A: Increase in blood pressure is not a direct indicator of the medication's effectiveness in this context.
C: Increase in lochia may be a sign of uterine involution but does not directly correlate with the effectiveness of methylergonovine.
D: Reporting of absent breast pain is not a specific indicator of the medication's effectiveness related to uterine contraction.
A client in active labor has 7 cm of cervical dilation, 100% effacement, and the fetus at 1+ station. The client's amniotic membranes are intact, but she suddenly expresses the need to push. What should the nurse do?
- A. Assist the client into a comfortable position.
- B. Observe the perineum for signs of crowning.
- C. Have the client pant during the next contractions.
- D. Help the client to the bathroom to void.
Correct Answer: C
Rationale: Rationale: Option C, having the client pant during the next contractions, is the correct answer. At 7 cm dilation with a sudden urge to push, it indicates possible fetal descent. Panting can help prevent rapid descent and reducing the risk of cervical edema or injury. It allows time for the cervix to dilate fully before pushing, preventing premature pushing and potential complications. Option A is not a priority at this stage. Option B is incorrect as observing for crowning might lead to premature pushing. Option D is not necessary as voiding is not the priority right now.
A nurse in a prenatal clinic is caring for a client who is at 7 weeks of gestation. The client reports urinary frequency and asks if this will continue until delivery. Which of the following responses should the nurse make?
- A. It's a minor inconvenience, which you should ignore.
- B. In most cases it only lasts until the 12th week, but it will continue if you have poor bladder tone.
- C. There is no way to predict how long it will last in each individual client.
- D. It occurs during the first trimester and near the end of the pregnancy.
Correct Answer: D
Rationale: The correct answer is D because urinary frequency is common in early pregnancy due to hormonal changes and pressure on the bladder from the growing uterus. This symptom typically improves by the end of the first trimester, as the uterus rises and reduces pressure on the bladder. Therefore, telling the client that it occurs during the first trimester and near the end of pregnancy is accurate.
Choice A is incorrect because urinary frequency should not be ignored as it could be a sign of a urinary tract infection or other underlying issue.
Choice B is incorrect because it inaccurately suggests that urinary frequency only lasts until the 12th week and implies that poor bladder tone is the sole factor influencing this symptom.
Choice C is incorrect because while it is true that individual experiences can vary, there are general patterns and timelines for common pregnancy symptoms like urinary frequency.