Nokea
A nurse is assessing a client who is in active labor and notes that the presenting part is at 0 station. Which of the following is the correct interpretation of this clinical finding?
- A. The fetal head is in the left occiput posterior position.
- B. The largest fetal diameter has passed through the pelvic outlet.
- C. The posterior fontanel is palpable.
- D. The lowermost portion of the fetus is at the level of the ischial spines.
Correct Answer: D
Rationale: Correct Answer: D. The lowermost portion of the fetus is at the level of the ischial spines.
Rationale:
1. Station 0 indicates the presenting part of the fetus is at the level of the ischial spines.
2. This position is significant as it helps determine the progress of labor.
3. It means the fetus has not descended into the birth canal yet, indicating early labor stages.
Summary:
A: Incorrect. Left occiput posterior position is related to fetal head position, not station.
B: Incorrect. Passing through the pelvic outlet refers to engagement, not station.
C: Incorrect. The posterior fontanel being palpable is not directly related to station.
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Alaska Natives experience higher levels of violence, poverty, and drug and alcohol use, and fewer resources. How can the nurse help these patients?
- A. Tell the patient to stop using substances.
- B. Provide resources that are specific for this population.
- C. Tell the patient to call the police.
- D. Report the abuse to the social worker.
Correct Answer: B
Rationale: The correct answer is B because providing resources specific to Alaska Natives addresses the unique challenges they face. This can include culturally sensitive support services, mental health resources, and community programs. Choice A is incorrect as simply telling the patient to stop using substances is not addressing the underlying issues. Choice C is inappropriate as telling the patient to call the police may not be safe or effective in all situations. Choice D is also incorrect as reporting abuse to a social worker may be necessary but does not directly address the patient's immediate needs for support and resources.
What is the priority action for a mother with a fever during labor?
- A. Administer antipyretics
- B. Provide IV antibiotics
- C. Encourage hydration orally
- D. Notify the healthcare provider immediately
Correct Answer: B
Rationale: The correct answer is B: Provide IV antibiotics. Fever during labor could indicate infection, which can be harmful to both the mother and baby. Administering IV antibiotics is the priority action to treat the infection promptly and prevent complications. Administering antipyretics only treats the symptom, not the underlying cause. Encouraging hydration orally may be important but should not take precedence over addressing a potential infection. Notifying the healthcare provider is important, but immediate intervention with antibiotics is crucial in this situation.
A nurse is planning care for a full-term newborn who is receiving phototherapy. Which of the following actions should the nurse include in the plan of care?
- A. Dress the newborn in lightweight clothing.
- B. Avoid using lotion or ointment on the newborn skin.
- C. Keep the newborn supine throughout treatment
- D. Measure the newborn's temperature every 8hr
Correct Answer: B
Rationale: The correct answer is B: Avoid using lotion or ointment on the newborn skin. Phototherapy is used to treat jaundice by exposing the baby's skin to light. Lotions or ointments can interfere with the effectiveness of the light therapy. Dressing the newborn in lightweight clothing (choice A) is not directly related to the effectiveness of phototherapy. Keeping the newborn supine throughout treatment (choice C) is a general position recommendation and not specific to phototherapy. Measuring the newborn's temperature every 8 hours (choice D) is important but not directly related to phototherapy.
Probable signs of pregnancy
- A. Ballottement (rebounding of the fetus against the examiner's fingers on palpation)
- B. Chadwicks sign (violet coloration of mucous membranes of cervix, vagina, and vulva @4 wks)
- C. Uterine enlargement
- D. Hegar's sign (compressibility and softening of lower uterine segment @6 wks)
Correct Answer: A
Rationale: The correct answer is A: Ballottement. This is a probable sign of pregnancy because it involves the rebounding of the fetus against the examiner's fingers on palpation. This occurs when the examiner pushes against the uterus and feels a bouncing back, indicating the presence of a fetus.
Choice B, Chadwick's sign, is actually the violet coloration of mucous membranes of cervix, vagina, and vulva at around 6-8 weeks, not 4 weeks as stated.
Choice C, uterine enlargement, is a presumptive sign of pregnancy as it can be caused by factors other than pregnancy, such as fibroids.
Choice D, Hegar's sign, involves the compressibility and softening of the lower uterine segment at around 6 weeks, but it is a probable sign rather than a definitive one like Ballottement.
What is the best nursing action for a newborn experiencing hypothermia?
- A. Place the newborn in skin-to-skin contact with the mother
- B. Provide a warm blanket and monitor temperature
- C. Administer IV fluids to stabilize temperature
- D. Monitor glucose levels for hypoglycemia
Correct Answer: A
Rationale: The correct answer is A: Place the newborn in skin-to-skin contact with the mother. This is the best nursing action for a newborn experiencing hypothermia because it provides immediate and effective warmth transfer from the mother to the baby. Skin-to-skin contact helps regulate the newborn's body temperature, promotes bonding, and enhances breastfeeding initiation.
Choice B is incorrect because while providing a warm blanket is important, skin-to-skin contact with the mother is more effective in quickly raising the newborn's temperature. Choice C is incorrect because administering IV fluids is not the first-line treatment for hypothermia in newborns. Choice D is incorrect because monitoring glucose levels for hypoglycemia is important but addressing the hypothermia should take precedence.