Nokea
A nurse is caring for a client who is at 40 weeks gestation and is in active labor. The client has 6 cm of cervical dilation and 100% cervical effacement. The nurse obtains the client's blood pressure reading as 82/52 mm Hg. Which of the following nursing interventions should the nurse perform?
- A. Prepare for a cesarean birth.
- B. Assist the client to an upright position.
- C. Prepare for an immediate vaginal delivery.
- D. Assist the client to turn onto her side.
Correct Answer: D
Rationale: Correct Answer: D - Assist the client to turn onto her side.
Rationale:
1. Side-lying position improves placental perfusion and circulation, optimizing blood pressure.
2. This position also helps in relieving pressure on major blood vessels, preventing hypotension.
3. It is a non-invasive intervention that can be quickly implemented in the labor setting.
Summary of Other Choices:
A: Preparing for a cesarean birth is not indicated based solely on the client's blood pressure reading.
B: Assisting the client to an upright position may further decrease blood pressure and compromise perfusion.
C: Immediate vaginal delivery is not warranted solely based on the client's blood pressure and cervical dilation.
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If pregnancy does not occur, the corpus luteum will disintegrate and turn into what is called the?
- A. Corpus albicans
- B. Corpus callosum
- C. Corpus cavernosum
- D. Corpus allatum OB Week 1 Practice Questions
Correct Answer: A
Rationale: The correct answer is A: Corpus albicans. After ovulation, if pregnancy does not occur, the corpus luteum regresses and degenerates into the corpus albicans, which is a white scar tissue in the ovary. This process marks the end of the ovarian cycle. The other options are incorrect: B: Corpus callosum is a structure in the brain, C: Corpus cavernosum refers to erectile tissue in the penis, and D: Corpus allatum is a neuroendocrine organ in insects.
What are signs of neonatal sepsis that a nurse should monitor for?
- A. Tachypnea, poor feeding, and temperature instability
- B. Increased alertness, reduced crying, and stable vitals
- C. Lethargy, poor perfusion, and apnea
- D. Hyperthermia, bradycardia, and cyanosis
Correct Answer: C
Rationale: The correct answer is C because lethargy, poor perfusion, and apnea are classic signs of neonatal sepsis. Lethargy indicates decreased activity and responsiveness, poor perfusion suggests inadequate blood circulation, and apnea is a serious respiratory issue. These signs indicate a systemic infection affecting multiple organs. Choices A, B, and D do not align with typical symptoms of neonatal sepsis. Tachypnea, poor feeding, and temperature instability (Choice A) are more general and can be seen in various conditions. Increased alertness, reduced crying, and stable vitals (Choice B) are not indicative of sepsis, as sepsis typically causes the opposite. Hyperthermia, bradycardia, and cyanosis (Choice D) can be present in sepsis, but they are not as specific or as common as the signs in Choice C.
The nurse provides education regarding male sterilization. What important information is provided?
- A. “Many people have vasectomies reversed.â€
- B. “You will need to return to the office to check for sperm in your ejaculate.â€
- C. “You will be sterile after 3 months.â€
- D. “Vasectomy consent forms must have both partners’ consent.â€
Correct Answer: B
Rationale: The correct answer is B: "You will need to return to the office to check for sperm in your ejaculate." This information is crucial as it ensures the success of the sterilization procedure. By checking for sperm in the ejaculate, the effectiveness of the vasectomy can be confirmed. This step is important to ensure that the individual is indeed sterile and can rely on the procedure for contraception.
Choice A is incorrect because vasectomy reversal is not always successful and should not be assumed. Choice C is incorrect as sterility is not immediate and may take several months after the procedure. Choice D is incorrect as consent forms for vasectomy typically require only the individual undergoing the procedure to give consent.
In summary, choice B is correct because it emphasizes the need for follow-up to confirm sterility, while the other choices provide incorrect or irrelevant information regarding male sterilization.
A client at 30 weeks' gestation is receiving magnesium sulfate for preterm labor. What assessment finding indicates magnesium toxicity?
- A. Deep tendon reflexes +3.
- B. Respiratory rate of 10 breaths per minute.
- C. Urine output of 40 mL/hour.
- D. Blood pressure of 120/80 mmHg.
Correct Answer: B
Rationale: The correct answer is B: Respiratory rate of 10 breaths per minute. Magnesium sulfate toxicity can lead to respiratory depression, resulting in a decreased respiratory rate. This is a critical sign of magnesium toxicity and should be addressed promptly.
Explanation for other choices:
A: Deep tendon reflexes +3 are actually a common finding in clients receiving magnesium sulfate due to its muscle relaxant effects.
C: Urine output of 40 mL/hour is within the normal range and does not indicate magnesium toxicity.
D: Blood pressure of 120/80 mmHg is also within the normal range and is not a sign of magnesium toxicity.
The nurse is teaching the postpartum client about newborn transitional stool. Which should the nurse include in the teaching session? SATA
- A. They have greenish brown color
- B. They are looser consistency
- C. They are seedy with sweet sour smell
- D. They have tar like consistency
Correct Answer: A
Rationale: The correct answer is A because transitional stools in newborns typically have a greenish-brown color due to the presence of meconium and the changing composition of the stool as the baby starts digesting breastmilk or formula.
Rationale:
1. A: Greenish-brown color is characteristic of transitional stools as meconium is being passed out.
Incorrect answers:
2. B: Transitional stools are not necessarily looser in consistency.
3. C: Transitional stools are not typically described as seedy with a sweet-sour smell.
4. D: Tar-like consistency is more indicative of meconium, not transitional stools.