Nokea
A pregnant person in the first stage of labor experiences rupture of membranes. What is the nurse's priority action?
- A. Administer an epidural for pain relief.
- B. Start an IV line and administer antibiotics.
- C. Document the FHR and time and characteristics of the amniotic fluid.
- D. Prepare for immediate delivery.
Correct Answer: C
Rationale: The correct answer is C because documenting the fetal heart rate (FHR) and characteristics of amniotic fluid is crucial to assess fetal well-being and monitor for signs of distress. This information helps guide further management decisions. Administering an epidural (A) is not the priority at this stage. Starting an IV line and administering antibiotics (B) may be needed later but not the immediate priority. Preparing for immediate delivery (D) is premature without assessing the fetal status first.
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Place these developmental milestones in chronological order: Four-chambered heart forms, Vernix caseosa appears, Blastocyst development completes, Testes descend
- A. Blastocyst development complete
- B. Four-chambered heart forms
- C. Vernix caseosa present
- D. Testes descend into scrotum
Correct Answer: B
Rationale: Development follows the sequence: blastocyst formation, four-chambered heart, vernix appearance, and testicular descent.
What item represents a serving of meat?
- A. Deck of cards
- B. Paperback book
- C. Clenched fist
- D. Large tomato
Correct Answer: A
Rationale: A serving of meat is approximately the size of a deck of cards, which equates to about 3 ounces.
For which patient would an L/S ratio of 2:1 potentially be considered abnormal?
- A. A 38-year-old gravida 2, para 1, who is 38 weeks’ gestation
- B. A 24-year-old gravida 1, para 0, who has diabetes
- C. A 44-year-old gravida 6, para 5, who is at term
- D. An 18-year-old gravida 1, para 0, who is in early labor at term
Correct Answer: B
Rationale: In diabetic pregnancies, an L/S ratio of 2:1 may not reliably indicate lung maturity due to delayed surfactant production.
A nurse is caring for a laboring person who is experiencing fetal bradycardia. What is the priority intervention?
- A. increase fluid intake
- B. administer oxygen
- C. monitor the fetal heart rate continuously
- D. place the laboring person on their left side
Correct Answer: B
Rationale: The correct answer is B: administer oxygen. Fetal bradycardia indicates reduced oxygen supply to the fetus, so providing oxygen to the laboring person can help increase oxygen levels for the fetus. This intervention is crucial to prevent further complications. Increasing fluid intake (A) may not address the immediate issue of fetal distress. Monitoring fetal heart rate continuously (C) is important but not the priority when immediate intervention is needed. Placing the laboring person on their left side (D) can help optimize fetal oxygenation, but administering oxygen is more direct and effective in this situation.
What is the first step the nurse should take when assessing a newborn's respiratory status immediately after birth?
- A. observe for respiratory effort
- B. take the newborn's temperature
- C. assist with suctioning the airways
- D. suction the newborn's mouth
Correct Answer: A
Rationale: The correct answer is A: observe for respiratory effort. This is the first step because it helps the nurse quickly assess if the newborn is breathing effectively. Observing for respiratory effort allows for prompt identification of any potential respiratory distress or abnormalities. Taking the newborn's temperature (B) is important but not the first step in assessing respiratory status. Assisting with suctioning the airways (C) should only be done if there are signs of airway obstruction, not as the initial step. Suctioning the newborn's mouth (D) is not recommended immediately after birth unless there is clear obstruction, as this can stimulate unnecessary reflexes and cause harm.