Nokea
A nurse is caring for a client who is in labor and reports increasing rectal pressure. They are experiencing contractions 2 to 3 min apart, each lasting 80 to 90 seconds, and a vaginal examination reveals that their cervix is dilated to 9 cm. The nurse should identify that the client is in which of the following phases of labor?
- A. Passive descent
- B. Active
- C. Early
- D. Descent
Correct Answer: B
Rationale: The correct answer is B: Active phase. At 9 cm dilation, the client is in the active phase of the first stage of labor. During this phase, contractions are strong and frequent, with the cervix dilating from 6 to 10 cm. The client may experience rectal pressure due to the baby descending. In the passive descent phase (choice A), the cervix is not fully dilated. Early phase (choice C) is typically from 0 to 6 cm dilation. Descent (choice D) is not a specific phase of labor. Other choices are not applicable in this context.
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A nurse is reviewing laboratory findings for a client who is at 20 weeks of gestation. Which of the following findings should the nurse report to the provider?
- A. Hematocrit 37% (37% to 47%)
- B. Creatinine 0.9 mg/dL (0.5 to 1 mg/dL)
- C. WBC count 11,000/mm3 (5,000 to 10,000/mm3)
- D. Fasting blood glucose 180 mg/dL (74 to 106 mg/dL)
Correct Answer: D
Rationale: The correct answer is D: Fasting blood glucose 180 mg/dL (74 to 106 mg/dL). Elevated fasting blood glucose levels during pregnancy can indicate gestational diabetes, which requires immediate attention to prevent complications for both the mother and the baby. The normal range for fasting blood glucose is 74 to 106 mg/dL; a value of 180 mg/dL is significantly elevated. The nurse should report this finding to the provider for further evaluation and management.
Choice A (Hematocrit 37%) falls within the normal range for a pregnant woman. Choice B (Creatinine 0.9 mg/dL) is within the normal range. Choice C (WBC count 11,000/mm3) is slightly elevated but not typically concerning during pregnancy. The focus should be on managing the high blood glucose level to ensure the health of the mother and baby.
Which of the following is a potential complication of neonatal hypernatremia?
- A. Hyperglycemia
- B. Hypoglycemia
- C. Dehydration
- D. All of the above
Correct Answer: C
Rationale: Neonatal hypernatremia can lead to dehydration due to excessive sodium levels.
Which of the following is a potential complication of a forceps-assisted delivery?
- A. Fetal distress
- B. Maternal hemorrhage
- C. Neonatal brachial plexus injury
- D. All of the above
Correct Answer: C
Rationale: Forceps-assisted delivery can sometimes result in neonatal brachial plexus injury due to the pressure applied during delivery.
A nurse is assessing a newborn who has neonatal abstinence syndrome. Which of the following findings should the nurse expect?
- A. Diminished deep tendon reflexes
- B. Excessive crying
- C. Decreased muscle tone
- D. Absent Moro reflex
Correct Answer: B
Rationale: The correct answer is B: Excessive crying. Neonatal abstinence syndrome (NAS) occurs in newborns exposed to addictive substances in utero. The newborn may exhibit symptoms such as excessive crying due to neurologic irritability. Diminished deep tendon reflexes (A) are not typically associated with NAS. Decreased muscle tone (C) is not a common finding in NAS; infants may actually have increased muscle tone. An absent Moro reflex (D) is not a typical finding in NAS, as hyperreflexia is more common.
Which of the following is a potential cause of male infertility?
- A. Azoospermia
- B. Oligospermia
- C. Teratospermia
- D. All of the above
Correct Answer: D
Rationale: Male infertility can be caused by azoospermia (no sperm), oligospermia (low sperm count), or teratospermia (abnormal sperm morphology).