Nokea
During active labor, after a sudden slowing of the fetal heart rate, the nurse assesses the woman's perineum and observes a prolapsed cord. Which nursing action is most appropriate?
- A. Hold the presenting part away from the cord
- B. Insert a scalp electrode for an internal fetal monitor
- C. Place the client in reverse Trendelenburg position
- D. Cover the cord with a dry,sterile gauze
Correct Answer: A
Rationale: The correct answer is A: Hold the presenting part away from the cord. This action helps relieve pressure on the cord, preventing further compromise of blood flow to the fetus. It is crucial to maintain fetal perfusion. Choice B (Insert a scalp electrode) and D (Cover the cord with gauze) are not appropriate as they do not address the immediate risk of cord compression. Choice C (Reverse Trendelenburg) may worsen the prolapse by shifting the presenting part higher.
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A nurse monitors fetal well-being by means of an external monitor. At the peak of the contractions, the fetal heart rate has repeatedly dropped 30 beats/min below the baseline. Late decelerations are suspected and the nurse notifies the physician. Which is the rationale for this action?
- A. A nuchal cord (cord around the neck) is associated with variable decelerations, not late decelerations.
- B. Variable decelerations (not late decelerations) are associated with cord compression.
- C. Late decelerations are a result of hypoxia. They are not reflective of the strength of maternal contractions.
- D. Late decelerations are associated with uteroplacental insufficiency and are a sign of fetal hypoxia. Repeated late decelerations indicate fetal distress.
Correct Answer: D
Rationale: The correct answer is D because late decelerations are associated with uteroplacental insufficiency, resulting in fetal hypoxia. This is a sign of fetal distress, as indicated by the repeated drops in fetal heart rate during contractions. Late decelerations occur after the peak of the contraction, reflecting the delayed recovery of the fetal heart rate due to inadequate oxygen supply from the placenta. This prompts the nurse to notify the physician for further evaluation and intervention to address the underlying cause of fetal distress. Choices A, B, and C are incorrect because they do not accurately describe the characteristics and causes of late decelerations in fetal monitoring.
A 1-year-old receives routine health maintenance care at the pediatric clinic. The child receives an MMR immunization. The mother asks the nurse, 'When will my child get the next dose of MMR vaccine?' Which is the correct response by the nurse?
- A. In six months with the next DPT
- B. No further vaccination needed
- C. With the Hepatitis B series
- D. After the child is 10 years of age
Correct Answer: D
Rationale: A second MMR, often called a booster, will be needed when the child enters middle school at age eleven or twelve years of age. This ensures full immunity from the diseases covered by the MMR vaccine.
A nurse is performing a routine physical examination on an adolescent client who asks, 'Why do I have to use a condom if my girlfriend is on the pill?' Which of the following is the most appropriate response by the nurse?
- A. You need to use two forms of birth control so if one fails you have a second form of protection against pregnancy.
- B. Using a condom allows you to share the responsibility for birth control.
- C. Oral contraceptives are less than 99 percent effective in adolescents. Therefore, a second form of contraception is needed.
- D. Oral contraceptives are highly effective in preventing pregnancy but do not prevent sexually transmitted diseases.
Correct Answer: D
Rationale: The correct answer is D. The nurse should explain that while oral contraceptives are highly effective in preventing pregnancy, they do not protect against sexually transmitted diseases (STDs). This is important because even if the girlfriend is on the pill, using a condom is necessary to prevent STD transmission. Adolescents are at higher risk for STDs, so it is crucial to emphasize the importance of dual protection. Choice A is incorrect as it does not specifically address the risk of STD transmission. Choice B is incorrect because it focuses on shared responsibility rather than the health implications of using a condom. Choice C is incorrect as it emphasizes the effectiveness of oral contraceptives rather than the need for STD protection.
Two hours after delivery the nurse assesses the client and documents that the fundus is soft, boggy, above the level of the umbilicus, and displaced to the right side. The nurse encourages the client to void. Which is the rationale for this nursing action?
- A. A full bladder prevents normal contractions of the uterus.
- B. An overdistended bladder may press against the episiotomy causing dehiscence.
- C. Distention of the bladder can cause urinary stasis and infection.
- D. It makes the client more comfortable when the fundus is massaged.
Correct Answer: A
Rationale: The correct answer is A: A full bladder prevents normal contractions of the uterus. A full bladder can impede the involution process of the uterus by exerting pressure on it, inhibiting proper contraction. This can lead to postpartum hemorrhage and increased risk of retained placental fragments. Encouraging the client to void helps to relieve the pressure on the uterus, allowing it to contract effectively and aiding in the expulsion of lochia and prevention of complications.
Other choices are incorrect because:
B: An overdistended bladder may press against the episiotomy causing dehiscence - While this is a potential risk, it is not directly related to fundal assessment and contraction.
C: Distention of the bladder can cause urinary stasis and infection - While true, this is not the primary concern when assessing the fundus post-delivery.
D: It makes the client more comfortable when the fundus is massaged - Massaging the fundus is a separate intervention and does
A nurse is providing teaching for a client who has a new prescription for combined oral contraceptives. Which of the following findings should the nurse include as an adverse effect of this medication?
- A. Depression
- B. Polyuria
- C. Hypotension
- D. Urticaria
Correct Answer: A
Rationale: The correct answer is A: Depression. Combined oral contraceptives are known to potentially cause mood changes, including depression, in some individuals due to hormonal fluctuations. This adverse effect is important for the nurse to include in teaching to monitor the client's mental health. Polyuria (B) is excessive urination, which is not typically associated with oral contraceptives. Hypotension (C) is low blood pressure, which is not a common side effect of this medication. Urticaria (D) is hives or skin rash, which is not a typical adverse effect of combined oral contraceptives.