Nokea
The nurse understands vitamin k is for?
- A. Not initially synthesized because of sterile bowel at birth (so they don't have enough clothing factors)
- B. Necessary for the production of platelets
- C. Important for production red blood cells
- D. Responsible for the breakdown of bilirubin and the prevention of jaundice
Correct Answer: D
Rationale: The correct answer is D because vitamin K is responsible for the breakdown of bilirubin in the liver, which helps prevent jaundice in newborns. Bilirubin is a product of the breakdown of old red blood cells, and vitamin K plays a crucial role in this process. Choice A is incorrect as sterile bowel does not affect vitamin K synthesis. Choice B is incorrect because platelet production is not directly related to vitamin K. Choice C is incorrect as red blood cell production is mainly regulated by other nutrients like iron, vitamin B12, and folate, not vitamin K.
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The nurse is assessing a client with suspected placenta previa. Which finding supports this diagnosis?
- A. Painful, bright red bleeding.
- B. Painless, bright red bleeding.
- C. Hard, rigid abdomen.
- D. Decreased fetal movements.
Correct Answer: B
Rationale: The correct answer is B: Painless, bright red bleeding. Placenta previa is characterized by painless vaginal bleeding due to the placenta covering the cervical os. Bright red blood indicates fresh bleeding from the lower uterus. This finding supports the diagnosis as it aligns with the classic presentation of placenta previa.
A: Painful, bright red bleeding is not characteristic of placenta previa, as the bleeding is usually painless.
C: A hard, rigid abdomen is more indicative of a uterine rupture or abruption, not placenta previa.
D: Decreased fetal movements are not directly associated with placenta previa; this finding may suggest fetal distress but is not specific to this condition.
Which client teaching instruction is necessary for a pregnant client who is to undergo a glucose challenge test (GCT) as part of a routine pregnancy treatment plan at 28 weeks?
- A. No dietary restriction (done 24-28 weeks' gestation)
Correct Answer: A
Rationale: The correct answer is A: No dietary restriction (done 24-28 weeks' gestation). This is because the glucose challenge test (GCT) is typically performed between 24-28 weeks of gestation to screen for gestational diabetes. It is important not to have any dietary restrictions before the test to ensure accurate results. Restricting food intake before the test can lead to false results. Other choices are incorrect because they do not align with the standard practice of performing the GCT between 24-28 weeks and avoiding dietary restrictions before the test.
What is the best position for a laboring mother with a suspected occiput posterior position?
- A. Encourage side-lying position
- B. Place the mother in lithotomy position
- C. Encourage ambulation to facilitate descent
- D. Use a peanut ball to widen the pelvis
Correct Answer: D
Rationale: The correct answer is D. Using a peanut ball widens the pelvis, which can help rotate the baby into an optimal position for birth. This position can aid in reducing the likelihood of prolonged labor and the need for interventions. Encouraging side-lying position (A) may not provide the necessary pelvic widening. Placing the mother in lithotomy position (B) can impede the baby's descent. Encouraging ambulation (C) may not specifically address the occiput posterior position and may not provide enough pelvic opening.
A charge nurse is teaching a group of staff nurses about fetal monitoring during labor. Which of the following findings should the charge nurse instruct the staff members to report to the provider?
- A. Contraction durations of 95 to 100 seconds
- B. Contraction frequency of 2 to 3 min apart
- C. Absent early deceleration of fetal heart rate
- D. Fetal heart rate is 140/min
Correct Answer: A
Rationale: The correct answer is A: Contraction durations of 95 to 100 seconds. Prolonged contractions can indicate uterine hyperstimulation, leading to decreased fetal oxygenation. Staff should report this to the provider for further evaluation and management.
Explanation:
1. Contraction durations of 95 to 100 seconds are prolonged and may indicate uterine hyperstimulation, potentially compromising fetal oxygenation.
2. Reporting this finding to the provider allows for timely intervention to prevent fetal distress.
3. Choices B, C, and D do not directly indicate a concern for fetal well-being during labor and would not require immediate reporting to the provider.
A client at 37 weeks' gestation reports swollen feet and hands. What assessment finding requires immediate intervention?
- A. Blood pressure of 150/95 mmHg.
- B. Weight gain of 1 pound in a week.
- C. Mild nausea after eating.
- D. Fetal movements are regular.
Correct Answer: A
Rationale: The correct answer is A: Blood pressure of 150/95 mmHg. This finding indicates gestational hypertension, which can progress to preeclampsia, a serious condition that requires immediate intervention to prevent complications for both the mother and baby. High blood pressure can lead to organ damage and placental insufficiency.
B: Weight gain of 1 pound in a week is within the normal range for late pregnancy and may not require immediate intervention.
C: Mild nausea after eating is a common pregnancy symptom and does not indicate an urgent issue.
D: Regular fetal movements are a positive sign of fetal well-being and do not require immediate intervention.