Nokea
A woman delivers a fetal demise that has lanugo covering the entire body, nails that are present on the fingers and toes, but eyes that are still fused. Prior to the death, the mother stated that she had felt quickening. Based on this information, the nurse knows that the baby is about how many weeks’ gestation?
- A. 15 weeks.
- B. 22 weeks.
- C. 29 weeks.
- D. 36 weeks.
Correct Answer: B
Rationale: Lanugo typically appears around 16-20 weeks and covers the entire body by 22-24 weeks. Nails begin forming at around 18-20 weeks and are fully developed by 22 weeks. Fused eyelids occur up until about 24-26 weeks, after which they open. Quickening (feeling of fetal movement) usually occurs between 18-22 weeks in first-time pregnancies. Therefore, the most likely gestational age is 22 weeks.
You may also like to solve these questions
A nurse is preparing to administer a postpartum tetanus shot. What is the most important action before administering the shot?
- A. verify the person's immunization status
- B. assess the person's blood pressure
- C. assess for uterine atony
- D. prepare for a cesarean section
Correct Answer: C
Rationale: Rationale:
C is correct because assessing for uterine atony is crucial before administering a postpartum tetanus shot to ensure no postpartum hemorrhage risk. Uterine atony can lead to excessive bleeding, which can be exacerbated by the tetanus shot.
Summary:
A - Verifying immunization status is important but not the most immediate action.
B - Assessing blood pressure is important but not directly related to the risk of postpartum hemorrhage.
D - Preparing for a cesarean section is not necessary for administering a postpartum tetanus shot.
A pregnant patient at 24 weeks gestation reports pain in the lower abdomen and back. What is the nurse's first priority action?
- A. Administer pain relief as prescribed and provide comfort measures.
- B. Assess the patient for signs of preterm labor, including regular contractions.
- C. Recommend the patient rest and apply heat to the affected area.
- D. Instruct the patient to lie flat on her back and monitor the symptoms.
Correct Answer: B
Rationale: The correct answer is B: Assess the patient for signs of preterm labor, including regular contractions. At 24 weeks gestation, lower abdominal and back pain can indicate preterm labor, a serious complication. The nurse's first priority should be to assess for signs such as regular contractions, vaginal bleeding, pelvic pressure, or changes in vaginal discharge. Prompt identification of preterm labor allows for timely interventions to prevent preterm birth and its associated risks. Administering pain relief (choice A) without assessing for preterm labor can delay necessary interventions. Recommending rest and heat application (choice C) may not address the underlying cause of the pain. Instructing the patient to lie flat on her back (choice D) may worsen symptoms and is not recommended in pregnancy.
A pregnant patient is at 34 weeks gestation and reports sudden sharp abdominal pain and difficulty breathing. What is the nurse's priority action?
- A. Encourage the patient to lie down and monitor the symptoms.
- B. Administer pain medication and schedule an ultrasound.
- C. Call the healthcare provider immediately and prepare for possible preterm labor.
- D. Assess the fetal heart rate and monitor for contractions.
Correct Answer: C
Rationale: The correct answer is C - Call the healthcare provider immediately and prepare for possible preterm labor. At 34 weeks gestation, sudden sharp abdominal pain and difficulty breathing could indicate a serious complication such as placental abruption or pulmonary embolism. Calling the healthcare provider ensures prompt assessment and appropriate intervention to prevent harm to the mother and baby. Encouraging the patient to lie down may delay necessary intervention. Administering pain medication before determining the cause of pain could mask important symptoms. Assessing the fetal heart rate and monitoring for contractions are important but secondary actions to calling the healthcare provider in this urgent situation.
A woman missed her menstrual period 1 week ago and has come to the doctor’s office for a pregnancy test. Which placental hormone is measured in pregnancy tests?
- A. Progesterone
- B. Estrogen
- C. Human chorionic gonadotropin
- D. Human placental lactogen
Correct Answer: C
Rationale: Human chorionic gonadotropin is the basis for most pregnancy tests. It is detectable in maternal blood as soon as implantation occurs, usually 7 to 9 days after fertilization.
The nurse is caring for a pregnant patient who has a history of gestational hypertension. Which intervention is most important to reduce the risk of complications?
- A. Monitor blood pressure regularly during pregnancy.
- B. Encourage the patient to exercise vigorously.
- C. Instruct the patient to eat a high-sodium diet.
- D. Advise the patient to reduce her fluid intake to avoid edema.
Correct Answer: A
Rationale: The correct answer is A: Monitor blood pressure regularly during pregnancy. Regular monitoring is crucial to detect any changes in blood pressure early and intervene promptly to prevent complications like preeclampsia.
Choice B is incorrect because vigorous exercise can increase blood pressure. Choice C is incorrect as a high-sodium diet can worsen hypertension. Choice D is incorrect as reducing fluid intake can lead to dehydration and potentially exacerbate hypertension. Regular blood pressure monitoring is key in managing gestational hypertension and ensuring the best outcomes for both the mother and the baby.