Nokea
A patient who uses a diaphragm as contraception asks if they need to use a backup method. What should the nurse respond?
- A. No, the diaphragm is effective on its own and does not require a backup method.
- B. Yes, a diaphragm is effective only when used with spermicide, so a backup method is advised.
- C. Yes, a diaphragm should always be used with a condom for additional protection.
- D. No, but the diaphragm should be replaced every 6 months.
Correct Answer: B
Rationale: The diaphragm should be used with spermicide for maximum effectiveness. Choice A is incorrect because while the diaphragm is effective, spermicide enhances its performance and ensures greater protection. Choice C is unnecessary, as the diaphragm alone with spermicide is sufficient. Choice D is incorrect because while regular replacement is recommended, it does not require a backup method.
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A nurse is caring for a client who is in the first stage of labor, undergoing external fetal monitoring, and receiving IV fluid. The nurse observes variable decelerations in the fetal heart rate on the monitor strip. Which of the following is a correct interpretation of this finding?
- A. Variable decelerations are due to umbilical cord compression.
- B. Variable decelerations are caused by uteroplacental insufficiency.
- C. Variable decelerations are a result of the administration of IV narcotic analgesics.
- D. Variable decelerations are related to fetal head compression.
Correct Answer: A
Rationale: Variable decelerations in the fetal heart rate are due to umbilical cord compression. These decelerations are characterized by an abrupt decrease in the fetal heart rate that is variable in duration, depth, and timing in relation to the uterine contraction. They can signify compression of the umbilical cord leading to transient interruption of fetal oxygen supply. It is essential for the nurse to promptly identify variable decelerations and take appropriate actions to alleviate the compression, such as repositioning the client to relieve pressure on the cord.
The nurse is monitoring a client who is 34 weeks ges- dividing?
- A. Trophoblast or inner cell mass that becomes the fetal monitor tracing are a priority for the nurse to placenta
- B. Embryoblast or inner cell mass that becomes the that apply. embryo
- C. Baseline FHR 140, accelerations, late decelerations,
- D. Morula
Correct Answer: A
Rationale: In the context of the question, the nurse is monitoring a 34-week gestation client. At 34 weeks, the trophoblast or inner cell mass has already developed into the placenta, which is formed earlier in pregnancy. Therefore, choice A is the most relevant option in this scenario. Trophoblast is critical for implantation and the formation of the placenta, which plays a vital role in supporting the developing fetus by providing oxygen and nutrients. Understanding the different stages of fetal development can help the nurse provide optimal care and monitor for any potential issues that may arise during pregnancy.
The nurse is teaching a prenatal class about labor. What statement indicates understanding?
- A. True labor contractions are irregular and stop with rest.
- B. False labor contractions cause cervical dilation.
- C. True labor contractions increase in intensity and frequency.
- D. False labor contractions are felt in the back.
Correct Answer: C
Rationale: True labor contractions become progressively stronger and lead to cervical dilation and effacement.
What is the primary purpose of administering vitamin K to a newborn?
- A. Prevent anemia
- B. Enhance immune function
- C. Prevent bleeding disorders
- D. Promote growth and development
Correct Answer: C
Rationale: Newborns are born with low levels of vitamin K, essential for blood clotting.
What teaching is most important for a mother with a newborn receiving phototherapy?
- A. Ensure the newborn wears protective eyewear
- B. Increase the newborn's fluid intake
- C. Turn the newborn frequently to prevent pressure sores
- D. Monitor bilirubin levels every 8 hours
Correct Answer: A
Rationale: Protective eyewear prevents retinal damage during phototherapy.