Nokea
A nurse midwife is examining a client who is a primigravida at 42 weeks of gestation and states that she believes she is in labor. Which of the following findings confirm to the nurse that the client is in labor
- A. Cervical dilation
- B. Report of pain above the umbilicus
- C. Brownish vaginal discharge
- D. Amniotic fluid in the vaginal vault
Correct Answer: A
Rationale: Cervical dilation is a key physiological change that confirms labor has begun. During the late stages of pregnancy, the cervix starts to soften, thin out (efface), and open up (dilate) in preparation for childbirth. Therefore, cervical dilation is a critical finding that indicates the onset of labor. Pain above the umbilicus, brownish vaginal discharge, and amniotic fluid in the vaginal vault are not definitive signs of labor and do not confirm the initiation of the labor process.
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The nurse is teaching a client about postpartum depression. What statement indicates understanding?
- A. It’s normal to feel hopeless for several weeks.
- B. Postpartum depression only occurs in first-time mothers.
- C. I should seek help if I feel disconnected from my baby.
- D. It is caused by a lack of support from family.
Correct Answer: C
Rationale: Feeling disconnected from the baby is a common symptom of postpartum depression and should prompt seeking help.
A newborn is delivered vaginally in the breech presentation. When examining her baby, the mother asks if the baby has been injured during birth because of the large black and blue areas on the buttocks and legs, The nurse should respond that:
- A. This is not a birth injury probably just a birthmark
- B. These are caused by forceps used to aid in the delivery of the baby
- C. This a temporary complication that will disappear in about a week
- D. These Mongolian spots, common in dark-skinned babies, disappear within a year
Correct Answer: A
Rationale: The large black and blue areas on the buttocks and legs of the newborn are likely Mongolian spots. Mongolian spots are common in infants with dark skin and are not a result of birth trauma. They are benign birthmarks caused by pigment that did not make it to the top layer of the skin before birth. These spots typically fade over time and may disappear completely within a few years. It is important to educate parents about Mongolian spots to alleviate any concerns they may have about their baby's skin markings.
The nurse is educating a client about gestational diabetes. What is the best recommendation for managing blood sugar levels?
- A. Avoid all carbohydrates.
- B. Exercise for 60 minutes daily.
- C. Eat balanced meals and monitor blood sugar levels.
- D. Only take insulin when blood sugar is high.
Correct Answer: C
Rationale: Balanced meals and regular blood sugar monitoring are essential for managing gestational diabetes.
A couple who has stated that they are LGBTQIA+ during prior visits arrives at the clinic for prenatal care. What can the nurse say in the waiting area to help them feel welcome and safe?
- A. You can take this tablet to an area in the waiting room and check in. Then bring the tablet back to me when you are done.
- B. Are you pregnant? Your paperwork says your name is Tom.
- C. You can have a seat, and a person from the LGBTQIA+ office will come to assist you.
- D. Here is our paperwork. It doesn't have a box for your sex, but you can write it next to the gender box.
Correct Answer: A
Rationale: Providing a neutral and respectful approach helps create a welcoming environment for LGBTQIA+ patients.
The newborn's mother is concerned about the shape of the baby's head after delivery. She states that the baby looks like a "cone head." What is the most appropriate response by the nurse?
- A. "You don't need to worry about it. It is perfectly normal after birth."
- B. "It is molding caused by the pressure during birth and will disappear in a few days."
- C. "I will report it to the physician and recommend a diagnostic scan."
- D. "It is a collection of blood related to the trauma of delivery and will absorb in a few weeks.
Correct Answer: B
Rationale: "It is molding caused by the pressure during birth and will disappear in a few days."