Nokea
A nurse is advising a pregnant woman about the danger signs of pregnancy. The nurse should teach the mother that she should notify the physician immediately if she experiences which of the following signs/symptoms? Select all that apply.
- A. Convulsions.
- B. Double vision.
- C. Epigastric pain.
- D. Persistent vomiting.
Correct Answer: D
Rationale: These symptoms may indicate severe complications such as preeclampsia, eclampsia, or hyperemesis gravidarum, requiring immediate medical attention. Polyuria is generally not a danger sign.
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During the first stage of labor, what is the primary goal of nursing care in the early phase?
- A. Administer pain medication.
- B. Monitor fetal heart rate continuously.
- C. Promote relaxation and provide comfort measures.
- D. Prepare for imminent delivery.
Correct Answer: C
Rationale: The correct answer is C because during the early phase of labor, the primary goal of nursing care is to promote relaxation and provide comfort measures to help the mother cope with contractions and manage pain. This helps create a calm and supportive environment, enhancing the progress of labor. Administering pain medication (A) may be necessary later, not necessarily in the early phase. Monitoring fetal heart rate continuously (B) is important but not the primary goal in the early phase. Preparing for imminent delivery (D) is premature in the early phase, as labor can be lengthy.
A nurse is assessing a laboring person for signs of fetal distress. What is the most common sign of fetal distress?
- A. increase oxygen flow
- B. tachycardia
- C. bradycardia
- D. irregular fetal heart rate
Correct Answer: B
Rationale: The correct answer is B: tachycardia. Fetal distress is often indicated by an increased fetal heart rate, known as tachycardia. This can be a sign of the fetus not receiving enough oxygen. Bradycardia (choice C) is a lower heart rate and not typically associated with fetal distress. Irregular fetal heart rate (choice D) may also indicate distress, but tachycardia is more commonly observed. Increasing oxygen flow (choice A) is a potential intervention for fetal distress but not a sign of distress itself. In summary, tachycardia is the most common sign of fetal distress due to potential oxygen deprivation.
What is the most common complication of a cesarean birth?
- A. infection
- B. hemorrhage
- C. urinary retention
- D. scar tissue
Correct Answer: A
Rationale: The correct answer is A: infection. Infection is the most common complication of a cesarean birth due to the incision made during the procedure, which can introduce bacteria. Infections can lead to various complications if not treated promptly. Hemorrhage (B) can occur but is less common than infection. Urinary retention (C) and scar tissue (D) are potential complications of cesarean birth but are not as common as infection.
What fetal change occurs when the fundal height reaches the xiphoid process?
- A. Surfactant forms in lungs
- B. Eyes begin to open and close
- C. Respiratory movements begin
- D. Spinal column is complete
Correct Answer: A
Rationale: Surfactant production begins in the lungs around this stage of pregnancy, preparing them for postnatal breathing.
What is the purpose of amniocentesis for a patient hospitalized at 34 weeks of gestation with pregnancy-induced hypertension?
- A. Determine if a metabolic disorder exists.
- B. Identify the sex of the fetus.
- C. Identify abnormal fetal cells.
- D. Determine fetal lung maturity.
Correct Answer: D
Rationale: At 34 weeks, amniocentesis is primarily used to assess fetal lung maturity, which is critical if early delivery is being considered.