Nokea
The nurse received end of shift report in a high-risk maternity unit. Which patient should the nurse see first?
- A. 26 weeks with placenta previa experiencing blood on toilet tissue after bowel movement (placenta is getting lower)
- B. 30 weeks' gestation with placenta previa whose fetal monitor shows late decelerations
- C. 35 weeks' gestation with grade I abruptio placenta in labor who has strong urge to push
- D. 37 weeks' gestation with pregnancy induced hypertension whose membrane ruptured spontaneously
Correct Answer: C
Rationale: The patient who should be seen first is the 35 weeks' gestation with grade I abruptio placenta in labor who has a strong urge to push. Abruptio placenta is a serious condition where the placenta detaches from the uterine wall before delivery, leading to significant bleeding and potential compromise to both the mother and baby. The strong urge to push indicates that the baby is in distress and immediate intervention is required to prevent potential harm. This patient needs urgent assessment and intervention to ensure the safety of both the mother and the baby.
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A nurse is caring for a client who is in labor. Which of the following nursing actions reflects application of the gate control theory of pain?
- A. Administer prescribed analgesic medication.
- B. Encourage the client to rest between contractions.
- C. Massage the client's back.
- D. Turn the client onto her left side.
Correct Answer: C
Rationale: The gate control theory of pain proposes that non-painful input can close the "gates" to painful input, which helps to control and reduce pain perception. Massage, such as massaging the client's back, is a non-pharmacological intervention that can help close the gates and reduce the perception of pain. By massaging the client's back, the nurse is applying this theory to help manage the client's labor pain. Administering analgesic medication (Choice A) is a pharmacological intervention and not specifically related to the gate control theory. Choices B and D are also beneficial nursing actions but do not directly relate to the gate control theory of pain.
A nurse is assessing a preterm newborn who is at 32 weeks of gestation. Which of the following finding should the nurse expect?
- A. Minimal arm recoil
- B. Popliteal angle of less than 90
- C. Creases over the entire sole
- D. Sparse lanugo
Correct Answer: B
Rationale: A preterm newborn at 32 weeks of gestation is usually characterized by hip flexion posturing and a popliteal angle of less than 90 degrees. The popliteal angle is the angle at the back of the knee joint when the leg is flexed, and a value of less than 90 degrees is commonly seen in preterm newborns due to their muscle tone immaturity. This finding is consistent with the developmental stage of a preterm infant at 32 weeks gestation.
The nurse is caring for a postpartum client who is
- A. Maternal hyperglycemia 1 day postcesarean birth. What assessment data
- B. FHR, early decelerations would indicate infection? Select all that apply.
- C. FHR, late decelerations
- D. Increased pulse
Correct Answer: A
Rationale: Maternal hyperglycemia 1 day post-cesarean birth can indicate infection. Hyperglycemia can impair immune function and make the body more susceptible to infections.
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.
What physical changes are more persistent and commonly experienced during menopause?
- A. secondary sex characteristics and growth spurt
- B. variable hot flushes and sleep difficulties
- C. thinning of skin and loss or dryness of hair
- D. irregular menstruation for a few years after menarche transition
Correct Answer: B
Rationale: