Nokea
The client delivered a 4200 g fetus. The physician performed a
midline episiotomy which extended into a 3rd degree laceration. The
client asks the nurse where she tore. Which response is best?
- A. Through your rectal sphincter
- B. Through your vaginal mucosa
- C. Through your cervix
- D. Through your bladder
Correct Answer: A
Rationale: The correct answer is A: Through your rectal sphincter. A 3rd degree laceration involves the perineal body and extends through the anal sphincter muscles. This type of laceration can occur with a midline episiotomy during childbirth. The rectal sphincter is a part of the anal canal and can be torn in severe cases. Choices B, C, and D are incorrect because a 3rd degree laceration does not involve the vaginal mucosa, cervix, or bladder. The tear is specifically related to the rectal area due to the extension of the episiotomy.
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A nurse is caring for a client who is at 40 weeks gestation and is in active labor. The client has 6 cm of cervical dilation and 100% cervical effacement. The nurse obtains the client's blood pressure reading as 82/52 mm Hg. Which of the following nursing interventions should the nurse perform?
- A. Prepare for a cesarean birth.
- B. Assist the client to an upright position.
- C. Prepare for an immediate vaginal delivery.
- D. Assist the client to turn onto her side.
Correct Answer: D
Rationale: Correct Answer: D - Assist the client to turn onto her side.
Rationale:
1. Side-lying position improves placental perfusion and circulation, optimizing blood pressure.
2. This position also helps in relieving pressure on major blood vessels, preventing hypotension.
3. It is a non-invasive intervention that can be quickly implemented in the labor setting.
Summary of Other Choices:
A: Preparing for a cesarean birth is not indicated based solely on the client's blood pressure reading.
B: Assisting the client to an upright position may further decrease blood pressure and compromise perfusion.
C: Immediate vaginal delivery is not warranted solely based on the client's blood pressure and cervical dilation.
A client at 28 weeks' gestation is undergoing a glucose tolerance test. What is the purpose of this test?
- A. To detect anemia.
- B. To screen for gestational diabetes.
- C. To assess fetal growth.
- D. To evaluate placental function.
Correct Answer: B
Rationale: The correct answer is B: To screen for gestational diabetes. The glucose tolerance test during pregnancy helps to identify women at risk for developing gestational diabetes, a condition that can lead to complications for both the mother and baby. By measuring blood sugar levels after consuming a glucose solution, healthcare providers can assess how the body processes sugar during pregnancy. This test is specifically designed to detect abnormalities in glucose metabolism during pregnancy.
Choice A: To detect anemia - Anemia is not typically identified through a glucose tolerance test. Anemia is usually diagnosed through a blood test that measures hemoglobin levels.
Choice C: To assess fetal growth - Fetal growth is usually monitored through ultrasound scans and measurements, not through a glucose tolerance test.
Choice D: To evaluate placental function - Placental function is evaluated through other tests like Doppler ultrasound, not through a glucose tolerance test.
What should health-care providers be attentive to during the trauma-informed gynecologic examination to avoid retraumatization? Select all that apply.
- A. providing information about trauma support resources
- B. establishing safety and trust
- C. recognizing signs of distress and offering support
- D. using trauma-sensitive language and communication
Correct Answer: B,C,D
Rationale: The correct answer is B, C, and D.
B: Establishing safety and trust is crucial to avoid retraumatization during the examination. It helps create a secure environment for the patient.
C: Recognizing signs of distress and offering support shows empathy and helps address any emotional reactions that may arise during the examination.
D: Using trauma-sensitive language and communication is essential to avoid triggering past traumas and ensuring clear and respectful communication.
Choices A is incorrect because while providing information about trauma support resources is important, it is not directly related to avoiding retraumatization during the examination.
The nurse is monitoring a client with hypertonic uterine contractions. What is the priority nursing action?
- A. Administer pain relief as prescribed.
- B. Prepare for an amniotomy.
- C. Encourage ambulation.
- D. Increase oxytocin infusion.
Correct Answer: A
Rationale: The correct answer is A: Administer pain relief as prescribed. The priority is to address the client's discomfort and pain caused by hypertonic uterine contractions. Pain management is crucial to ensure the client's comfort and well-being. Administering pain relief can help prevent complications such as increased stress on the mother and fetus.
Choice B: Prepare for an amniotomy is incorrect because it involves artificial rupturing of the amniotic sac, which is not indicated for hypertonic contractions.
Choice C: Encourage ambulation is incorrect because it may exacerbate the pain and discomfort experienced by the client with hypertonic uterine contractions.
Choice D: Increase oxytocin infusion is incorrect because it can further intensify the uterine contractions and worsen the client's pain.
The nurse is reviewing a prenatal client’s record. Which history finding increases the risk for preeclampsia?
- A. Advanced maternal age.
- B. History of gestational diabetes.
- C. First pregnancy.
- D. History of anemia.
Correct Answer: C
Rationale: The correct answer is C: First pregnancy. Preeclampsia is more common in first pregnancies due to the body's lack of adaptation to the pregnancy. In subsequent pregnancies, the body has already gone through the changes necessary for pregnancy, reducing the risk. Advanced maternal age (A) and history of gestational diabetes (B) are risk factors for other pregnancy complications but not specifically preeclampsia. History of anemia (D) is not directly linked to an increased risk of preeclampsia.