Nokea
A patient with an IUD in place has a positive pregnancy test. When planning care, the nurse will base decisions on which anticipated action?
- A. A therapeutic abortion will need to be scheduled since fetal damage is inevitable.
- B. Hormonal analyses will be done to determine the underlying cause of the false-positive test result.
- C. The IUD will need to be removed to avoid complications such as miscarriage or infection.
- D. The IUD will need to remain in place to avoid injuring the fetus.
Correct Answer: C
Rationale: Rationale:
C is correct because when a patient with an IUD in place has a positive pregnancy test, the IUD should be removed to avoid complications such as ectopic pregnancy, miscarriage, or infection. Leaving the IUD in place can increase the risk of adverse outcomes for both the mother and the fetus. Removing the IUD allows for safer management of the pregnancy and reduces potential harm.
Summary:
A: Incorrect. Fetal damage is not inevitable, and a therapeutic abortion is not the immediate action required in this situation.
B: Incorrect. Hormonal analyses are not the priority when a positive pregnancy test with an IUD in place is detected.
D: Incorrect. Leaving the IUD in place can lead to complications and is not the recommended course of action.
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A young man is planning to use the condom as a contraceptive device. The nurse should teach him that which of the following actions is needed to maximize the condom's effectiveness?
- A. Use only water-soluble lubricants.
- B. Use only natural lambskin condoms.
- C. Apply the condom to a flaccid penis.
- D. Apply it tightly to the tip of the penis.
Correct Answer: A
Rationale: Water-soluble lubricants should be used with condoms to prevent breakage. Natural lambskin condoms do not protect against STIs, and condoms should be applied to an erect penis.
The nurse is caring for a client in labor and delivery with the following history: G2 P1000, 39 weeks' gestation in transition phase, FH 135 with early decelerations. The client states, 'I'm so scared. Please make sure the baby is OK!' Which of the following responses by the nurse is appropriate?
- A. There is absolutely nothing to worry about.
- B. The fetal heart rate is within normal limits.
- C. How did your first baby die?
- D. Was your first baby preterm?
Correct Answer: B
Rationale: The fetal heart rate of 135 with early decelerations is within normal limits, which is reassuring. The nurse should provide factual information to alleviate the client's anxiety.
The nurse is caring for a client who had a contraction stress test. Which change in assessment requires immediate notification of the health care provider?
- A. No late decelerations
- B. Late decelerations with at least 50% of the contractions
- C. Accelerations with contractions
- D. No contractions produced
Correct Answer: B
Rationale: The correct answer is B because late decelerations with at least 50% of contractions indicate fetal distress and potential hypoxia. This requires immediate notification of the healthcare provider for further evaluation and intervention. No late decelerations (choice A) are normal. Accelerations with contractions (choice C) are reassuring. No contractions produced (choice D) would indicate an inadequate test and require reevaluation.
The results of a contraction stress test (CST) are positive. Which intervention is necessary based on this test result?
- A. Repeat the test in 1 week so that results can be trended based on this baseline result.
- B. Contact the health care provider to discuss birth options for the patient.
- C. Send the patient out for a meal and repeat the test to confirm that the results are valid.
- D. Ask the patient to perform a fetal kick count assessment for the next 30 minutes and then reassess the patient.
Correct Answer: B
Rationale: The correct answer is B because a positive contraction stress test (CST) indicates potential fetal distress, requiring immediate medical attention. Contacting the health care provider is necessary to discuss birth options for the patient, such as potential induction or cesarean section to prevent harm to the fetus.
A is incorrect because waiting another week could pose risks to the fetus if distress is already present. C is incorrect as sending the patient out for a meal and repeating the test is not a valid or necessary intervention. D is incorrect as a fetal kick count assessment does not address the immediate concerns raised by a positive CST result.
The nurse is preparing to assist with the insertion of an intrauterine pressure catheter and a fetal spiral electrode. What is required for proper placement by the practitioner? Select all that apply.
- A. Rupture of membranes
- B. Dilated cervix
- C. Vertex fetus
- D. Moderate variability
Correct Answer: A
Rationale: Correct Answer: A - Rupture of membranes
Rationale:
1. Rupture of membranes is necessary for the insertion of intrauterine pressure catheter and fetal spiral electrode.
2. It allows safe passage of the catheter and electrode into the uterus.
3. Without ruptured membranes, there is a risk of infection and difficulty in inserting the devices.
Summary:
- Choice B (Dilated cervix) is not required for the insertion of these devices.
- Choice C (Vertex fetus) is not a factor in the insertion process.
- Choice D (Moderate variability) is related to fetal heart rate monitoring, not device insertion.