Nokea
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.
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A nurse is completing a health history for a client who is at 6-week gestation. The client informs the nurse that she smokes one park of cigarettes per day. The nurse should advise the client that smoking places the client9s newborn at risk for what complication?
- A. Hearing loss
- B. Intrauterine growth restriction
- C. Type 1 diabetes mellitus
- D. Congenital heart defects
Correct Answer: B
Rationale: The correct answer is B: Intrauterine growth restriction (IUGR). Smoking during pregnancy can restrict blood flow to the fetus, leading to inadequate oxygen and nutrients, resulting in IUGR. This can lead to low birth weight and potential health complications for the newborn. Hearing loss (A) is not directly associated with smoking during pregnancy. Type 1 diabetes mellitus (C) is an autoimmune condition not caused by maternal smoking. Congenital heart defects (D) can be a risk with smoking during pregnancy, but the most direct risk is IUGR.
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.
The nurse is performing a prenatal assessment. What finding is considered a positive sign of pregnancy?
- A. Positive pregnancy test.
- B. Auscultation of fetal heart tones.
- C. Hegar's sign.
- D. Chadwick's sign.
Correct Answer: B
Rationale: The correct answer is B, auscultation of fetal heart tones, because it is a definitive sign of pregnancy indicating the presence of a fetus. This can be heard around 10-12 weeks of gestation using a Doppler device. It is a positive sign as it directly confirms the existence of a developing fetus.
A: A positive pregnancy test is a probable sign and can indicate pregnancy but is not definitive.
C: Hegar's sign is a probable sign characterized by softening of the lower uterine segment, not specific to pregnancy.
D: Chadwick's sign is a probable sign of pregnancy indicated by bluish discoloration of the cervix, vagina, and labia, not a definitive sign of pregnancy.
A client at 20 weeks' gestation reports leg cramps. What recommendation should the nurse provide?
- A. Increase potassium intake.
- B. Stretch the legs before bed.
- C. Drink fluids during meals.
- D. Reduce physical activity.
Correct Answer: B
Rationale: The correct answer is B: Stretch the legs before bed. Leg cramps during pregnancy are common due to increased weight and pressure on blood vessels. Stretching before bed helps prevent cramps by improving circulation and muscle relaxation. Increasing potassium intake (choice A) can help with muscle function but is not the primary intervention for leg cramps. Drinking fluids during meals (choice C) is important for hydration but does not directly address leg cramps. Reducing physical activity (choice D) may worsen circulation and muscle cramps.
A woman is 16 weeks pregnant and she had cramping backache and mild bleeding for the past 3 days. The HCP determines she is dilated 2cm, 10% effaced, membranes intact. She's crying and saying to the nurse is my baby going to be okay? In addition to acknowledging the patient's fear the nurse should also say:
- A. Your cervix has begun to dilate, this is a serious sign, we will continue to monitor you and the baby for now
- B. I really can't say but when your physicians arrive, I'll ask her talk to you about it
- C. You baby will be fine, we will start an IV and get this stopped in no time at all
- D. You are going to miscarry, but you should be relieved because most miscarriages are the result of abnormalities in the fetus
Correct Answer: A
Rationale: Step 1: Acknowledge the patient's fear and anxiety.
Step 2: Provide a clear and honest response regarding the situation.
Step 3: Explain the significance of cervical dilation at 16 weeks.
Step 4: Assure the patient that they will be closely monitored.
Step 5: Offer support and comfort to the patient.
Summary:
Choice A is correct because it addresses the patient's concerns, acknowledges the seriousness of the situation, provides information about cervical dilation, and reassures the patient about monitoring. Choices B, C, and D are incorrect because they do not provide accurate information or address the situation appropriately, which could further distress the patient.