Nokea
A nurse is caring for a client who is receiving oxytocin for induction of labor and notes late decelerations of the fetal heart rate on the monitor Tracing. Which of the following action should the nurse take?
- A. Decrease maintenance IV solution infusion rate.
- B. Place the client in lateral position.
- C. Administer misoprostol 25 mcg vaginally D
- D. Administer oxygen via face mask at 2 L/min
Correct Answer: B
Rationale: Late decelerations of the fetal heart rate can indicate uteroplacental insufficiency, which may be a result of decreased oxygen supply to the fetus. Placing the client in a lateral position can help enhance uteroplacental perfusion by relieving pressure on the vena cava and improving maternal blood flow to the placenta. This position change can help improve fetal oxygenation and decrease the occurrence of late decelerations. Other actions such as administering oxygen and assessing for other contributing factors should also be done, but placing the client in a lateral position is the most appropriate immediate intervention in this scenario.
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A client at 28 weeks' gestation reports uterine contractions every 10 minutes. What is the priority nursing action?
- A. Encourage rest and hydration.
- B. Assess for signs of preterm labor.
- C. Administer tocolytic medication.
- D. Perform a vaginal examination.
Correct Answer: B
Rationale: Assessing for preterm labor signs, including cervical changes, is critical to determine the appropriate intervention.
A nurse is caring for a client who is in preterm labor at 32 weeks of gestation. The client asks the nurse, "Will my baby be okay?" Which of the following responses should the nurse offer?
- A. "You must be feeling scared and powerless."
- B. "Everyone worries about her baby when she's in labor."
- C. "Your pregnancy is advanced so your baby should be fine."
- D. "We have a neonatal unit here that's equipped to handle emergencies."
Correct Answer: D
Rationale: The most appropriate response for the nurse to offer in this situation is to inform the client that there is a neonatal unit equipped to handle emergencies. This response provides the client with reassurance that if there are any complications with the baby being born prematurely, there is a specialized unit available to provide the necessary care. It addresses the client's concern about the well-being of her baby while also offering a practical solution in case of any emergencies.
A new mother states that her infant must be cold because the baby's head and feet are blue? The nurse should explain that this is a common and temporary condition called:
- A. Acrocyanosis
- B. Vernix caseosa
- C. Erythema neonatorum
- D. Harlequin color
Correct Answer: A
Rationale: Acrocyanosis is a common and benign condition in newborn infants characterized by temporary blueness or cyanosis of the hands, feet, and sometimes the face. This blueness is caused by the temporary constriction of blood vessels in those areas, resulting in reduced blood flow and less oxygen reaching the skin. Acrocyanosis typically resolves on its own and does not indicate any serious health concerns in newborns. It is important for healthcare providers to reassure parents that acrocyanosis is a normal phenomenon in newborns and does not require treatment.
During which cycle day of a typical 28-day menstrual cycle does the follicular phase occur?
- A. Cycle days 1-14
- B. Cycle days 7-14
- C. Cycle days 1-6
- D. Cycle days 14-28
Correct Answer: A
Rationale: The follicular phase is the first phase of the menstrual cycle, during which the follicles in the ovaries mature in preparation for ovulation. In a typical 28-day menstrual cycle, the follicular phase occurs from cycle days 1 to 14. Ovulation usually takes place around day 14, marking the end of the follicular phase and the beginning of the luteal phase. During the follicular phase, the levels of estrogen gradually increase, stimulating the thickening of the uterine lining and the development of a dominant follicle containing the egg that will be released at ovulation.
A 26-year-old woman is interested in using an IUD for contraception. What is the primary advantage of using an IUD over other contraceptive methods?
- A. It requires no daily action from the patient once inserted.
- B. It provides immediate protection after insertion.
- C. It is effective immediately after the first sexual activity after insertion.
- D. It is effective only for 6 months before needing replacement.
Correct Answer: A
Rationale: One of the primary advantages of the IUD is that it requires no daily action, making it a convenient and reliable method. Choice B is incorrect because it may take a few days for some types of IUDs to provide full protection. Choice C is incorrect because immediate protection may not be ensured immediately after insertion, especially for hormonal IUDs. Choice D is incorrect because IUDs typically last for several years, not just 6 months.