Nokea
A nurse is preparing to assess fetal heart tones for a client who is at 12 weeks of gestation. Which of the following actions should the nurse take?
- A. Place the client in a side-lying position prior to assessing the fetal heart rate
- B. Measure the fundal height to determine the placement of the ultrasound stethoscope.
- C. Position the ultrasound stethoscope above the symphysis pubis to assess the fetal heart rate.
- D. Perform Leopold maneuvers prior to auscultating the fetal heart rate.
Correct Answer: C
Rationale: At 12 weeks of gestation, the fetal heart rate is best assessed by placing the ultrasound stethoscope above the symphysis pubis, where the uterus is located.
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Which of the following hormones is responsible for maintaining the uterine lining during pregnancy?
- A. Progesterone
- B. Estrogen
- C. Prolactin
- D. Oxytocin
Correct Answer: A
Rationale: Progesterone is responsible for maintaining the uterine lining during pregnancy, supporting the developing fetus.
A nurse is reviewing the prescriptions for a client who is pregnant and is taking digoxin. Which of the following actions should the nurse take to best evaluate the client’s medication adherence?
- A. Ask the client if they are taking the medication as prescribed.
- B. Assess the client’s kidney function.
- C. Determine the client’s apical pulse rate.
- D. Check the client’s serum medication level.
Correct Answer: D
Rationale: The correct answer is D: Check the client’s serum medication level. This is the best action to evaluate medication adherence for digoxin in a pregnant client. Serum medication levels provide an objective measure of how much of the drug is present in the body, indicating if the client is taking the medication as prescribed. Asking the client directly (choice A) may not always yield accurate information. Assessing kidney function (choice B) is important for monitoring potential side effects of digoxin but does not directly assess medication adherence. Determining the apical pulse rate (choice C) is important for monitoring digoxin therapy but does not evaluate medication adherence.
Which of the following is a potential ethical issue related to neonatal intensive care?
- A. Allocation of resources
- B. Withholding or withdrawing life-sustaining treatment
- C. Use of alternative therapies without informed consent
- D. All of the above
Correct Answer: D
Rationale: All of the above are potential ethical issues in neonatal intensive care. Allocation of resources raises questions about fairness, withholding or withdrawing treatment involves difficult decisions about quality of life, and using alternative therapies without consent violates patient autonomy.
The nurse is assessing the client 30 min later. How should the nurse interpret the findings? For each finding, click to specify whether the finding is unrelated to the diagnosis, an indication of potential improvement, or an indication of potential worsening condition.
- A. Fundus at level of umbilicus
- B. Cloudy urine
- C. Blood pressure 80/50 mm Hg
- D. Moderate lochia rubra
- E. Thready pulse
- F. Fundus firm to palpation
Correct Answer:
Rationale: Findings indicating improvement: Fundus at umbilicus, Moderate lochia rubra, Fundus firm to palpation Findings indicating worsening: Blood pressure 80/50 mm Hg, Thready pulse Unrelated finding: Cloudy urine Clinical Implication: The nurse should urgently address the low blood pressure and thready pulse, as they indicate ongoing hemodynamic instability due to postpartum hemorrhage. Immediate interventions such as IV fluids, blood transfusion, and further uterotonic medications may be necessary.
Which stage of labor is characterized by cervical dilation from 4-10 cm?
- A. First stage
- B. Second stage
- C. Third stage
- D. Fourth stage
Correct Answer: A
Rationale: The correct answer is A: First stage. This stage of labor is characterized by cervical dilation from 4-10 cm. During this stage, the cervix prepares for childbirth by thinning and opening up to allow the baby to pass through the birth canal. The first stage is further divided into early labor (0-4 cm dilation) and active labor (4-10 cm dilation). It is crucial for monitoring progress and determining when to move to the next stage of labor. The other choices are incorrect because the second stage is characterized by pushing and delivery of the baby, the third stage is delivery of the placenta, and the fourth stage is the postpartum period immediately after delivery.