Nokea
A nurse is caring for a client who is at 39 weeks of gestation and is in active labor. The nurse locates the fetal heart tones above the client's umbilicus at midline. The nurse should suspect that the fetus is in which of the following positions?
- A. Cephalic
- B. Transverse
- C. Posterior
- D. Frank breech
Correct Answer: A
Rationale: When the nurse locates the fetal heart tones above the client's umbilicus at midline, it indicates that the fetus is in a cephalic position. In this position, the baby's head is facing downward towards the birth canal, which is the optimal position for a vaginal delivery. This positioning is considered normal and favorable for childbirth.
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A woman is experiencing mittelschmerz and increased vaginal discharge. Her temperature has increased by 0.6°C (1.0°F) over the past 36 hours. This most likely indicates what?
- A. Menstruation is about to begin.
- B. Ovulation will occur soon.
- C. Ovulation has occurred.
- D. She is pregnant, and will not menstruate.
Correct Answer: C
Rationale: Mittelschmerz, or mid-cycle pain, combined with a basal temperature rise and cervical mucus changes, is a sign that ovulation has occurred. These indicators are part of the body's natural fertility signals.
A nurse is caring for a client who is gravida 3, para 2, and is in active labor. The fetal head is at 3+ station after a vaginal examination. Which of the following actions should the nurse take
- A. Apply fundal pressure.
- B. Observe for the presence of a nuchal cord.
- C. Observe for crowning.
- D. Prepare to administer oxytocin.
Correct Answer: C
Rationale: Observing for crowning is the appropriate action for the nurse to take when the fetal head is at 3+ station after a vaginal examination. Crowning refers to the appearance of the baby's head at the vaginal opening during delivery. This indicates that the baby is descending and will be born soon. It is important for the nurse to be prepared for the actual birth once crowning is observed, as it signifies that the second stage of labor is progressing and delivery is imminent. Applying fundal pressure, observing for a nuchal cord, or preparing to administer oxytocin are not appropriate actions at this stage of labor when crowning has been observed.
A nurse is caring for a client who is receiving oxytocin to augment labor. The nurse notes recurrent variable decelerations...Which of the following actions should the nurse take first?
- A. Prepare the equipment necessary to initiate an amnioinfusion.
- B. Administer oxygen at 10 L/min via nonrebreather face mask.
- C. Discontinue the infusion of oxytocin.
- D. Place the client in a left lateral position.
Correct Answer: C
Rationale: Recurrent variable decelerations during labor can indicate umbilical cord compression, which can result in fetal hypoxia and distress. Discontinuing the oxytocin infusion is the priority in this situation as oxytocin can cause or exacerbate uteroplacental insufficiency leading to fetal distress. By discontinuing the oxytocin, the nurse can help improve fetal oxygenation and alleviate the variable decelerations. After stopping the oxytocin infusion, the nurse should continue to monitor the fetal heart rate pattern and follow the healthcare provider's orders for further management if needed.
After her baby's birth a patient wishes to begin breastfeeding. The nurse assists the client by:
- A. Positioning the infant to grasp the nipple to express milk.
- B. Giving the infant a bottle first to evaluate the baby's ability to suck
- C. Leaving them alone and allowing the infant to nurse as long as desired
- D. Touching the infant's cheek adjacent to the nipple to elicit the rooting reflex
Correct Answer: A
Rationale: Positioning the infant to grasp the nipple to express milk is an essential step in helping the patient begin breastfeeding successfully. As a nurse, it is crucial to ensure that the infant is properly latched onto the breast to facilitate effective feeding and milk transfer. This involves positioning the infant in a way that allows them to effectively grasp the nipple, promoting proper suckling and milk production. By assisting the patient in positioning the infant correctly, the nurse is supporting the establishment of successful breastfeeding and ensuring optimal nutrition for the baby.
Teratogens are substances or agents that can cause congenital abnormalities or birth defects in a developing embryo or fetus during pregnancy. What is a true statement about teratogens?
- A. Vitamins can help prevent abnormalities due to teratogens.
- B. Their impact on the fetus depends on factors such as timing and duration of exposure during pregnancy.
- C. They include only medications that a pregnant person may take.
- D. They can be avoided by immunizations.
Correct Answer: B
Rationale: