Nokea
A nurse is reviewing the record of a woman who has just been told that she is pregnant. The physician has documented the presence of Goodell’s sign. The nurse determines this sign refers to which of the following?
- A. A softening of the tip of the cervix
- B. A soft blowing sound that corresponds to the maternal pulse
- C. Enlargement of the uterus
- D. A softening of the lower uterine segment
Correct Answer: A
Rationale: The correct answer is A: A softening of the tip of the cervix. Goodell's sign is a softening of the tip of the cervix, which is one of the early signs of pregnancy due to increased vascularity and edema. This sign is often used by healthcare providers to confirm pregnancy.
Rationale:
1. Goodell's sign specifically refers to the softening of the cervix, not any other part of the reproductive system.
2. It is an important early sign of pregnancy due to hormonal changes.
3. Enlargement of the uterus (Choice C) typically occurs later in pregnancy, not as an early sign.
4. A blowing sound corresponding to maternal pulse (Choice B) and softening of the lower uterine segment (Choice D) are not associated with Goodell's sign.
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What type of dystocia occurs when the fetal head is unable to navigate through the pelvis?
- A. uterine dystocia
- B. fetal dystocia
- C. pelvic dystocia
- D. contraction dystocia
Correct Answer: C
Rationale: The correct answer is C: pelvic dystocia. Pelvic dystocia occurs when the fetal head is unable to navigate through the pelvis due to its size, shape, or orientation. This can lead to prolonged labor and potential complications during delivery. Uterine dystocia (A) refers to abnormalities in uterine contractions, fetal dystocia (B) pertains to issues with the fetus itself, and contraction dystocia (D) involves problems with the strength or coordination of uterine contractions. Pelvic dystocia specifically addresses the anatomical mismatch between the fetal head and maternal pelvis, making it the correct choice in this scenario.
In preparation for a cesarean birth, the nurse expects which medical-based preoperative interventions? Select all that apply.
- A. Administration of narrow-spectrum prophylactic antibiotics
- B. Verification that the woman has been NPO for 6 to 8 hours before surgery
- C. Assessment of the woman’s knowledge and educational needs
- D. Assessment for risk of venous thromboembolism (VTE)
Correct Answer: B
Rationale: The correct answer is B because being NPO (nothing by mouth) for 6 to 8 hours before surgery helps prevent aspiration during anesthesia. Option A is incorrect because broad-spectrum antibiotics are typically used to cover a wider range of potential pathogens. Option C is not a medical-based preoperative intervention. Option D, while important, is more related to postoperative care rather than preoperative interventions.
What nursing intervention is performed during labor for a person with preeclampsia?
- A. Assess deep tendon reflexes for hyperreflexia.
- B. Provide frequent IV fluid boluses.
- C. Educate the laboring person that preeclampsia is only a concern for pregnancy, not labor.
- D. Discourage pain medication in order to assess for headache.
Correct Answer: A
Rationale: The correct answer is A: Assess deep tendon reflexes for hyperreflexia. This is crucial in preeclampsia to monitor for signs of worsening condition like eclampsia. Hyperreflexia is a common symptom in severe preeclampsia indicating CNS irritability. Providing IV fluid boluses (B) can worsen fluid overload. Educating that preeclampsia is only a concern for pregnancy (C) is incorrect as it can progress during labor. Discouraging pain medication (D) is inappropriate as it can mask symptoms like headaches, a common sign of worsening preeclampsia.
The physician has ordered an amnioinfusion for the laboring patient. Which data supports the use of this therapeutic procedure?
- A. Presenting part not engaged
- B. +4 meconium-stained amniotic fluid on artificial rupture of membranes (AROM)
- C. Breech position of fetus
- D. Twin gestation
Correct Answer: B
Rationale: The correct answer is B because +4 meconium-stained amniotic fluid on AROM indicates meconium passage by the fetus, which can lead to meconium aspiration syndrome. Amnioinfusion can help dilute the meconium, reducing the risk of respiratory complications for the newborn.
A: Presenting part not engaged is not a direct indication for amnioinfusion.
C: Breech position of the fetus does not specifically warrant amnioinfusion.
D: Twin gestation alone is not a direct indication for amnioinfusion.
The nurse is providing care in PACU for a patient who just delivered a neonate via cesarean section. The patient reports tightness in her chest. Assessment findings include tachypnea, hypotension, and decreasing oxygen saturation levels. Which complication does the nurse report to the health care provider?
- A. Pulmonary embolism
- B. Postpartum hemorrhage
- C. Surgical-site infection
- D. Developing endometritis
Correct Answer: A
Rationale: The correct answer is A: Pulmonary embolism. The patient's symptoms of chest tightness, tachypnea, hypotension, and decreasing oxygen saturation levels are indicative of a potential pulmonary embolism, which is a serious complication post-cesarean section. A pulmonary embolism occurs when a blood clot travels to the lungs, causing respiratory distress and cardiovascular compromise. The nurse should report this immediately to the healthcare provider for prompt intervention to prevent further complications.
Incorrect choices:
B: Postpartum hemorrhage - Symptoms of postpartum hemorrhage include excessive bleeding, not chest tightness and respiratory distress.
C: Surgical-site infection - Symptoms of surgical-site infection include redness, swelling, and drainage at the incision site, not chest tightness and respiratory distress.
D: Developing endometritis - Symptoms of endometritis include fever, pelvic pain, and abnormal vaginal discharge, not chest tightness and respiratory distress.