Nokea
During the first postpartum checkup, the nurse is assessing whether the client’s chloasma has diminished. At which anatomical location is the nurse performing the assessment?
- A. Perineum
- B. Abdomen
- C. Breasts
- D. Face
Correct Answer: D
Rationale: Chloasma does not appear on the perineum. Chloasma does not appear on the abdomen. Chloasma does not appear on the breasts. The nurse should be assessing the skin over the cheeks, nose, and forehead for chloasma.
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The nurse correctly explains that fertilization usually takes place in which structure?
- A. Fallopian tube
- B. Ovary
- C. Uterus
- D. Vagina
Correct Answer: A
Rationale: Fertilization typically occurs in the fallopian tube, where the sperm meets the ovum after ovulation.
The nurse is caring for the client in preterm labor who has gestational diabetes. The nurse determines that the client has a reactive NST when which findings are noted?
- A. Two fetal heart rate (FHR) accelerations of 15 beats per minute (bpm) above baseline for at least 15 seconds in a 20-minute period
- B. An FHR acceleration of 15 bpm above baseline for at least 10 seconds in the 40-minute time period for the NST
- C. Two FHR accelerations of 20 bpm above baseline when the mother changes position during the 20-minute NST
- D. The occurrence of at least three mild repetitive variable decelerations in the 20-minute time period for the NST
Correct Answer: A
Rationale: The FHR is monitored by the placement of an electronic fetal monitor that has an ultrasound transducer to record the FHR and a tocodynamometer to detect uterine or fetal movement. The client is given a handheld marker to indicate when she feels fetal movement. Fetal movement is accompanied by an increase in the FHR in the healthy fetus. The criterion for a reactive (normal) NST is the presence of two FHR accelerations of 15 bpm above baseline lasting 15 seconds or longer in a 20-minute period. One FHR acceleration during a 40-minute period is insufficient and indicates a nonreactive (abnormal) NST. Maternal movement can cause an inconsistency in the FHR on the monitor strip and should be avoided during an NST. The occurrence of at least three mild repetitive variable decelerations in a 20-minute period describes a nonreactive (abnormal) NST and fetal intolerance.
How early in a pregnancy can the nurse expect to hear the fetal heartbeat using a Doppler device?
- A. 4 to 6 weeks
- B. 8 to 10 weeks
- C. 12 to 14 weeks
- D. 16 to 18 weeks
Correct Answer: C
Rationale: A fetal heartbeat can typically be detected by Doppler around 12-14 weeks, when the fetus is sufficiently developed.
The nurse is teaching the pregnant client during her first trimester. The nurse identifies that which decision is most important for her to make first?
- A. Bottle versus breastfeeding
- B. Labor and delivery location
- C. Pain management during labor
- D. Method for delivery of the baby
Correct Answer: B
Rationale: A decision regarding labor and delivery location is the priority for the client in order to properly plan for a home birth versus a hospital birth, HCP availability at the location, and type of labor and delivery settings available at the location. The decision on feeding the newborn can be made up to the time of the first feeding. The decision on pain management can be made early but can be changed up through the early stages of labor. The decision of delivery method should be made early but cannot be determined until the decision is made on labor and delivery location.
The postpartum client suffered a fourth-degree perineal laceration during her vaginal birth. Which interventions should the nurse add to the client’s plan of care? Select all that apply.
- A. Limit ambulation to bathroom privileges only.
- B. Decrease fluid intake to 1000 mL every 24 hours.
- C. Instruct the client on a high-fiber diet.
- D. Monitor the uterus for firmness every 2 hours.
- E. Give pm prescribed stool softeners in the am. and at h.s.
Correct Answer: C,E
Rationale: Activity should be increased, not decreased, to reduce the potential for constipation. Fluids should be increased, not decreased, to reduce the potential for dehydration and constipation. The client with a fourth-degree perineal laceration should be instructed to increase dietary fiber to help maintain bowel continence and decrease perineal trauma from constipation. A perineal laceration will not affect the condition of the uterus; there is no need to increase uterine monitoring. The client with a fourth-degree perineal laceration should be given a stool softener bid to help maintain bowel continence and decrease perineal trauma from constipation.