Nokea
A pregnant woman tells the nurse-midwife, 'I've heard that if I eat certain foods during my pregnancy, the baby will be a boy.' The nurse-midwife should explain that this is a myth, and that the sex of the baby is determined at what time?
- A. At the time of ejaculation
- B. At the time of fertilization
- C. At the time of implantation
- D. At the time of differentiation
Correct Answer: B
Rationale: The sex of a baby is determined at fertilization. Sperm cells carry either an X or Y chromosome, while the ovum only carries an X chromosome. If the sperm contributes an X chromosome, the baby will be female, and if it contributes a Y chromosome, the baby will be male.
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What is the priority nursing action for a newborn with a temperature of 35.5°C (95.9°F)?
- A. Place the newborn under a radiant warmer
- B. Administer warm IV fluids
- C. Swaddle the newborn in warm blankets
- D. Provide glucose supplementation
Correct Answer: A
Rationale: Placing the newborn under a radiant warmer helps raise body temperature and prevent complications.
The nurse is caring for a client in labor with an epidural. What assessment is most important immediately after placement?
- A. Monitor maternal temperature.
- B. Assess for lower extremity weakness.
- C. Monitor maternal blood pressure.
- D. Check fetal presentation.
Correct Answer: C
Rationale: Maternal blood pressure monitoring is essential to detect and manage hypotension caused by epidural anesthesia.
What is the primary nursing concern for a mother receiving magnesium sulfate therapy?
- A. Monitor blood pressure every 4 hours
- B. Monitor deep tendon reflexes hourly
- C. Assess respiratory rate and effort
- D. Prepare for delivery if signs of toxicity appear
Correct Answer: B
Rationale: Monitoring reflexes detects early signs of magnesium toxicity.
The nurse is monitoring a pregnant client with severe preeclampsia. Which finding requires immediate intervention?
- A. Blood pressure of 140/90 mmHg.
- B. Urine output of 30 mL/hr.
- C. Complaints of headache and blurred vision.
- D. Weight gain of 1 pound in one week.
Correct Answer: C
Rationale: Headache and blurred vision are signs of worsening preeclampsia, indicating potential eclampsia.
4 minutes after the birth of the baby there is a sudden gush of blood from the mom's vagina and the about 8 inches of umbilical cord slides out. What action should nurse take first?
- A. Watch for emergence of placenta
- B. Assess for signs of uterine inversion
- C. Perform fundal massage
- D. Prepare for possible episiotomy repair
Correct Answer: A
Rationale: In this situation, the nurse should first watch for the emergence of the placenta. This is because the gush of blood followed by the umbilical cord slipping out indicates a possible placental abruption, where the placenta separates from the uterine wall before the baby is born. It is crucial to closely monitor the situation for signs of an incomplete placental delivery or any further complications. If the placenta does not deliver within a reasonable timeframe or if there are signs of excessive bleeding or other issues, immediate medical intervention may be necessary.