Nokea
A nurse is performing a routine assessment on a client who is at 18 weeks of gestation. Which of the following findings should the nurse expect?
- A. Deep tendon reflexes 4+
- B. Fundal height 14 cm
- C. Blood pressure 142/94 mm Hg
- D. FHR 152/min
Correct Answer: D
Rationale: The correct answer is D: FHR 152/min. At 18 weeks gestation, the fetal heart rate (FHR) typically ranges from 140-160 beats per minute, making 152/min within the normal range. This finding indicates a healthy fetal heart rate.
A: Deep tendon reflexes 4+ is not relevant to a routine assessment at 18 weeks gestation.
B: Fundal height of 14 cm is more indicative of around 12 weeks gestation, not 18 weeks.
C: Blood pressure of 142/94 mm Hg is elevated and would require further assessment and management, not expected at 18 weeks gestation.
In summary, the FHR of 152/min is the expected finding at 18 weeks gestation, making it the correct answer.
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A nurse is providing teaching to a client who is 2 days postpartum and wants to continue using her diaphragm for contraception. Which of the following instructions should the nurse include?
- A. You should have your provider refit you for a new diaphragm.'
- B. You should use an oil-based vaginal lubricant when inserting your diaphragm.'
- C. You should keep the diaphragm in place for at least 4 hours after intercourse.'
- D. You should store your diaphragm in sterile water after each use.'
Correct Answer: A
Rationale: The correct answer is A: "You should have your provider refit you for a new diaphragm." This is important because postpartum changes in the body can affect the fit of the diaphragm. A refitting ensures proper size and fit for effective contraception. Choice B is incorrect because oil-based lubricants can damage latex diaphragms. Choice C is incorrect as the diaphragm should be kept in place for at least 6-8 hours, not 4 hours, for effective contraception. Choice D is incorrect as diaphragms should be stored dry, not in sterile water, to prevent damage.
A nurse is transporting a newborn back to the parent's room following a procedure. Which of the following actions should the nurse take prior to leaving the newborn with their parent?
- A. Ensure that the parent's identification band number matches the newborn's identification band number.
- B. Ask the parent to verify their name and date of birth.
- C. Check the newborn's security tag number to ensure it matches the newborn's medical record.
- D. Match the newborn's date and time of birth to the information in the parent's medical record.
Correct Answer: A
Rationale: The correct answer is A: Ensure that the parent's identification band number matches the newborn's identification band number. This is crucial for patient safety and identification to prevent mix-ups. Matching the identification band numbers ensures that the newborn is returned to the correct parent. Checking the parent's identification ensures that the parent is indeed the one authorized to receive the newborn. Choices B, C, and D do not directly address the vital step of verifying the parent-newborn match through identification band numbers, making them incorrect.
A nurse is caring for a newborn who has jaundice and a new prescription for phototherapy. Which of the following actions should the nurse take?
- A. Provide the newborn with 15 mL glucose water after each feeding.
- B. Turn the newborn every 4 hr.
- C. Apply hydrating lotion to the newborn’s skin prior to treatment.
- D. Close the newborn's eyes before applying eyepatches.
Correct Answer: D
Rationale: The correct answer is D: Close the newborn's eyes before applying eyepatches. This is important to protect the newborn's eyes from exposure to the bright light used in phototherapy, which can cause damage if the eyes are left open. Closing the eyes with eyepatches ensures that the light therapy is safely administered without harming the eyes.
A: Providing glucose water is not relevant to managing jaundice with phototherapy.
B: Turning the newborn every 4 hours is important for preventing pressure ulcers, but it is not directly related to phototherapy.
C: Applying hydrating lotion is not necessary before phototherapy and may interfere with the treatment.
E, F, G: Not provided.
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 9cm dilation, the client is transitioning from the latent phase to the active phase of the first stage of labor. In the active phase, contractions are stronger and more frequent, leading to increased rectal pressure and cervical dilation. This phase typically ranges from 6-10cm dilation. Passive descent (A) refers to the early phase of labor when the cervix is dilating but contractions are mild. Early phase (C) is characterized by 0-3cm dilation. Descent (D) is not a recognized phase of labor. The client's symptoms align with the characteristics of the active phase, making option B the correct choice.
A nurse is caring for a client who is at 38 weeks of gestation. Which of the following actions should the nurse take prior to applying an external transducer for fetal monitoring?
- A. Determine progression of dilatation and effacement.
- B. Perform Leopold maneuvers.
- C. Complete a sterile speculum exam.
- D. Prepare a Nitrazine paper test.
Correct Answer: B
Rationale: The correct answer is B: Perform Leopold maneuvers. Prior to applying an external transducer for fetal monitoring at 38 weeks of gestation, the nurse should perform Leopold maneuvers to determine the position of the fetus, fetal lie, presentation, and engagement. This helps in locating the fetal back and identifying the optimal placement for the transducer. Progression of dilatation and effacement (choice A) is more relevant for labor assessment. Completing a sterile speculum exam (choice C) is not necessary for fetal monitoring. Preparing a Nitrazine paper test (choice D) is used to assess for rupture of membranes, not for applying an external transducer.