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How would a patient who has taken Lamaze education respond when the health-care provider recommends breaking the bag of waters in early labor?
- A. As long as it will speed up my labor, that is fine.â€
- B. I trust whatever intervention you think is right.â€
- C. What are the risks and benefits of breaking my water right now?â€
- D. Will I be able to get an epidural after you break my water?â€
Correct Answer: C
Rationale: Lamaze encourages informed decision-making, prompting patients to ask about risks and benefits.
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The nurse is teaching a client about signs of labor. Which symptom indicates true labor?
- A. Irregular contractions that stop with activity.
- B. Contractions felt in the abdomen only.
- C. Cervical dilation and effacement.
- D. Absence of fetal movement.
Correct Answer: C
Rationale: True labor is characterized by regular contractions that cause cervical dilation and effacement.
During a nursing assessment the woman with rupture
- A. What is the nurse's priority action?
- B. Use gravity and manipulation to relieve compression of the cord (butt up in the air and face down until ready to delivery)
- C. Help the fetal head descend faster
- D. Facilitate dilation of the cervix with prostaglandin gel
Correct Answer: A
Rationale: In the scenario presented, the nurse's priority action should be to call for emergent medical assistance. A woman with a rupture during a nursing assessment could be experiencing a serious complication known as umbilical cord prolapse. This occurs when the umbilical cord slips through the cervix ahead of the baby, which can lead to compression of the cord and a serious decrease in oxygen supply to the baby. It is a medical emergency that requires immediate intervention by the healthcare team, which may include moving the mother into a knee-chest position or performing a cesarean section. Therefore, the priority action for the nurse is to ensure prompt medical intervention to protect the well-being of both the mother and the baby.
Positive signs of pregnancy
- A. FHR detected by electronic doppler @10-12 wks
- B. Active fetal movements palpable by examiner
- C. Outline of fetus by radiography or ultrasound
Correct Answer: B
Rationale: One of the positive signs of pregnancy is the active fetal movements palpable by the examiner. This occurs when the examiner is able to feel the movements of the fetus inside the uterus. This sign usually becomes noticeable in the second half of pregnancy and is a clear indication that the pregnancy is progressing normally. It is a reassuring sign for both the pregnant individual and the healthcare provider that the fetus is active and healthy.
The nurse is assessing a client with suspected preeclampsia. What symptom supports this diagnosis?
- A. Hyperglycemia.
- B. Proteinuria.
- C. Increased fetal movement.
- D. Hypotension.
Correct Answer: B
Rationale: Proteinuria is a hallmark symptom of preeclampsia, along with hypertension and other systemic findings.
A nurse is providing teaching to a group of women about risk factors for ovarian cancer. Which of the following should the nurse include? (Select all that apply.)
- A. Nulliparity
- B. History of breastfeeding (???)
- C. Previous use of oral contraceptives
- D. History of breast cancer
Correct Answer: A
Rationale: A. Nulliparity: Women who have never been pregnant (nulliparity) are at an increased risk for ovarian cancer compared to women who have had full-term pregnancies. This is thought to be due to the protective effect of pregnancy and childbirth on the ovaries.