Nokea
The nurse is caring for a G5 in labor. The membrane
- A. Which nursing action is most important to undertake at this time?
- B. Complete sterile vaginal exam
- C. Assess odor of amniotic fluid
- D. Perform Leopold's maneuver
Correct Answer: A
Rationale: The most important nursing action to undertake at this time is obtaining a fetal heart rate (FHR) assessment. Monitoring the FHR is crucial during labor to assess the well-being of the baby and detect any signs of fetal distress. This information helps guide the healthcare team in determining the appropriate course of action to ensure the safety of both the mother and baby. It takes precedence over other tasks such as completing a sterile vaginal exam, assessing the odor of amniotic fluid, performing Leopold's maneuver, or obtaining pain medication orders. Monitoring the FHR should be the immediate priority in this situation.
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An infertility specialist is evaluating whether a woman's cervical mucus contains enough estrogen to support sperm motility. Which of the following tests is the physician conducting?
- A. Ferning capacity
- B. Basal body temperature
- C. Colposcopy
- D. Hysterotomy
Correct Answer: A
Rationale: Ferning capacity refers to the ability of cervical mucus to form a fern-like pattern under a microscope when it is close to ovulation. This pattern indicates the presence of estrogen, which is essential for supporting sperm motility. By assessing ferning capacity, the infertility specialist can determine if the woman's cervical mucus contains enough estrogen to facilitate the movement of sperm for successful fertilization. This test helps in evaluating the quality of cervical mucus and its role in the fertility process. The other options (Basal body temperature, Colposcopy, Hysterotomy) are not directly related to assessing estrogen levels in cervical mucus for sperm motility.
What education does the nurse provide to a person taking Ella for emergency contraception?
- A. abstain from sex or use a barrier method for 5 days and then restart their COCs
- B. abstain from sex or use a barrier method until their menses occur and then restart their COCs
- C. restart their COCs the next day; no backup method is needed
- D. restart their COCs the next day and use a backup method for 7 days
Correct Answer: D
Rationale: The education the nurse should provide to a person taking Ella for emergency contraception is to restart their COCs the next day and use a backup method, such as condoms, for 7 days. This is important to ensure continued protection against pregnancy, as Ella may potentially reduce the effectiveness of the COCs. Using a backup method during this time is essential to prevent unintended pregnancy.
A delivering patient presses the call light and reports that her water just broke the nurse first action should be:
- A. Check the fetal heart tone
- B. Call physician
- C. Change bed linen
- D. Encourage mother to go for a walk
Correct Answer: A
Rationale: The correct first action when a delivering patient's water breaks is to check the fetal heart tone. This is important to assess the well-being of the baby and ensure there are no signs of distress. Once the fetal heart tone is confirmed, the nurse can proceed with notifying the physician, changing bed linen, and encouraging the mother to go for a walk as needed. But the priority should always be to assess the fetal well-being in such a situation.
Which statement by the patient helps the nurse know
- A. Follicle-stimulating hormone she understands the teaching about condom use?
- B. Gonadotropin-releasing hormone
- C. A condom can be worn for two sexual encounters
- D. Progesterone as long as it does not break.
Correct Answer: A
Rationale: The statement "Condoms come in different sizes; it is important I get the right size to ensure proper protection" indicates that the patient understands the teaching about condom use. This statement shows an understanding of the importance of choosing the appropriate condom size for effective protection during sexual encounters. It reflects the patient's grasp of the information provided by the nurse regarding condom use, which is crucial in promoting safe practices to prevent sexually transmitted infections and unintended pregnancies.
A nurse is caring for a client who has preeclampsia and is being treated with magnesium sulfate IV. The client's respiratory rate is 10/min and deep-tendon reflexes are absent. Which of the following actions should the nurse take?
- A. Discontinue the medication infusion.
- B. Prepare for an emergency cesarean birth.
- C. Assess maternal blood glucose.
- D. Place the client in Trendelenburg position.
Correct Answer: A
Rationale: The most appropriate action for the nurse to take in this situation is to discontinue the medication infusion. The client is showing signs of magnesium sulfate toxicity, which can include respiratory depression (low respiratory rate) and absent deep-tendon reflexes. These are early signs of magnesium toxicity, and prompt action is needed to prevent further complications. Discontinuing the medication infusion will help reduce the risk of magnesium toxicity worsening. The other options are not appropriate in this situation as they do not address the immediate concern of magnesium toxicity.