Nokea
A nurse is caring for a client who is 36 weeks pregnant and reports leaking fluid. Which of the following tests should the nurse use to confirm that the client¢â‚¬â„¢s membranes have ruptured?
- A. Nonstress test
- B. Biophysical profile
- C. Fern test
- D. Amniocentesis
Correct Answer: C
Rationale: The fern test is used to confirm rupture of membranes. A sample of vaginal fluid is examined under a microscope, and the presence of a fern-like pattern indicates the presence of amniotic fluid.
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A postpartum complication a client is at risk for is deep-vein thrombosis. Which of the following is a factor strongly associated with this postpartum complication?
- A. Cesarean birth
- B. Vaginal birth
- C. Anemia
- D. Multiparity
Correct Answer: A
Rationale: Cesarean birth doubles the risk for deep-vein thrombosis (DVT) due to immobility and vascular changes associated with surgery. Other risk factors include smoking, obesity, and a history of thromboembolism.
A nurse is providing education to a client in the first trimester of pregnancy. What information should the nurse include regarding the cause of indigestion and heartburn?
- A. Estrogen causes increased appetite
- B. Progesterone causes relaxation of the cardiac sphincter allowing acid to reflux
- C. HCG hormone leads to increased gastric acidity
- D. The uterus compresses the stomach early in pregnancy
Correct Answer: B
Rationale: Progesterone causes relaxation of the smooth muscles in the body, including the cardiac sphincter. This allows stomach acid to reflux into the esophagus, causing heartburn, especially during pregnancy.
A nurse is assessing a client who gave birth 12 hr ago and is experiencing excessive vaginal bleeding. Which of the following findings indicates the client is experiencing decreased cardiac output?
- A. Bradycardia
- B. Flushed face
- C. Hypotension
- D. Polyuria
Correct Answer: C
Rationale: Hypotension is a key indicator of decreased cardiac output, especially in the context of postpartum hemorrhage, which can lead to significant fluid volume loss and compromise perfusion.
A nurse is caring for a client in active labor who is receiving oxytocin. The nurse notes that the client is experiencing contractions every 1 minute lasting 90 seconds. Which of the following actions should the nurse take?
- A. Stop the oxytocin infusion
- B. Administer oxygen
- C. Increase the IV fluid rate
- D. Prepare for delivery
Correct Answer: A
Rationale: Contractions that are too frequent or prolonged can lead to uterine hyperstimulation, which can compromise fetal oxygenation. The nurse should stop the oxytocin infusion to reduce contraction frequency and intensity.
A nurse is caring for a client who is in active labor and notes late decelerations in the FHR on the external fetal monitor. Which of the following actions should the nurse take first?
- A. Change the client's position
- B. Palpate the uterus to assess for tachysystole
- C. Increase the client's IV infusion rate
- D. Administer oxygen at 10 L/min via nonrebreather mask
Correct Answer: A
Rationale: The first action should be to change the client's position, as this can relieve pressure on the umbilical cord and improve fetal oxygenation, addressing the cause of late decelerations.