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 explains that, in addition to increased blood volume, which other condition causes varicose veins during pregnancy?
- A. Impaired venous return
- B. Decreased cardiac output
- C. Altered center of gravity
- D. Impaired kidney function
Correct Answer: A
Rationale: Impaired venous return, due to the uterus compressing veins, causes varicose veins, compounded by increased blood volume.
The laboring client is experiencing problems, and the nurse is concerned about possible side effects from the epidural anesthetic just administered. Which problems should the nurse attribute to the epidural anesthetic? Select all that apply.
- A. Has breakthrough sharp pain
- B. Blood pressure is increased
- C. Has a pounding headache
- D. Unable to feel a full bladder
- E. Has an elevated temperature
Correct Answer: A,C,D,E
Rationale: Breakthrough pain can occur when the continuous infusion rate of the anesthetic agent is below the recommended rate for a therapeutic dose. Breakthrough pain can also occur when the client has a full bladder or when the cervix is completely dilated. A spinal headache can be a complication of epidural anesthesia and occurs when the dura is accidently punctured during epidural placement. A sensory level of T10 is usually maintained during epidural anesthesia; most women are unable to feel a full bladder or to void after receiving an epidural anesthetic. Maternal temperature may be elevated to 100.1°F (37.8°C) or higher with an epidural. Sympathetic blockade may decrease sweat production and diminish heat loss. Hypertension is a contraindication for epidural anesthesia. A major side effect of epidural anesthesia is hypotension (not hypertension) caused by a spinal blockade, which lowers peripheral resistance, decreases venous return to the heart, and subsequently lessens cardiac output and lowers BP.
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.
Which safety measure should the nurse emphasize for newborn sleep?
- A. Place the newborn on their back to sleep
- B. Use soft bedding for comfort
- C. Co-sleep in the parent's bed
- D. Keep the room very warm
Correct Answer: A
Rationale: Placing the newborn on their back to sleep reduces the risk of sudden infant death syndrome (SIDS).
The nurse, admitting a 40-week primigravida to the labor unit, just documented the results of a recent vaginal exam: 3/100/—2, RSP. How should the oncoming shift nurse interpret this documentation?
- A. The fetus is approximately 2 cm below maternal ischial spines.
- B. The cervix is totally dilated and effaced, with fetal engagement.
- C. The fetus is breech and posterior to the client’s pelvis.
- D. The fetal lie is transverse, and the fetal attitude is flexion.
Correct Answer: C
Rationale: The nurse should interpret 3/100/—2, RSP as the cervix is 3 cm dilated, 100% effaced, and the fetus is 2 cm above the maternal ischial spines. RSP means that the fetus is to the right of the mother’s pelvis (R), with the sacrum as the specific presenting part (S), which is a breech position. This fetus is also posterior (P). At —2, the fetus is 2 cm above, not below, the maternal ischial spines. Two centimeters below the ischial spines would be recorded as +2. The cervix is 3 cm, not totally dilated. Total dilation would be documented as 10 for the first number. Also, the cervix is 100% effaced, which is total effacement (shortening and thinning out). Fetal lie (relationship of long axis or spine of fetus to long axis of mother) is longitudinal, not transverse. The documentation does not specify if the fetal attitude is flexion.