Nokea
The nurse is monitoring a client in active labor. What finding indicates the need for immediate intervention?
- A. Contractions every 2–3 minutes.
- B. Fetal heart rate of 90 beats/minute.
- C. Cervical dilation of 6 cm.
- D. Client reports back pain.
Correct Answer: B
Rationale: A fetal heart rate of 90 beats/minute is bradycardia, indicating potential fetal distress.
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What cycle day does the proliferative stage occur?
- A. Cycle day 7-14
- B. Cycle day 14-28
- C. Cycle day 1-6
- D. Cycle day 1-14
Correct Answer: A
Rationale: The proliferative stage of the menstrual cycle occurs from around cycle day 7 to cycle day 14. This stage is characterized by the growth of the endometrial lining of the uterus in response to increasing levels of estrogen produced by the developing ovarian follicles. The proliferative stage prepares the uterus for a potential embryo implantation following ovulation, which typically occurs around day 14 of a 28-day menstrual cycle.
What is the primary reason for administering Rh immunoglobulin to an Rh-negative mother after delivery?
- A. To prevent maternal sensitization in future pregnancies
- B. To treat postpartum hemorrhage
- C. To reduce the risk of infection
- D. To boost maternal immune response
Correct Answer: A
Rationale: Rh immunoglobulin prevents maternal sensitization to Rh-positive blood.
The nurse is monitoring a client with suspected placental abruption. What is a key assessment finding?
- A. Painless vaginal bleeding.
- B. Hard, rigid abdomen with severe pain.
- C. Clear amniotic fluid.
- D. Regular uterine contractions.
Correct Answer: B
Rationale: A hard, rigid abdomen and severe pain are classic signs of placental abruption, requiring urgent intervention.
The nurse is explaining how a newly delivered baby initiates respiration. Which statement explains this process?
- A. Chemical thermal and mechanical factors
- B. Increase of po2 and decreased pco2
- C. Continued function of foramen ovale
- D. Drying off the infant
Correct Answer: A
Rationale: The correct statement explaining how a newly delivered baby initiates respiration is "Chemical thermal and mechanical factors." When a baby is born, various factors come into play to stimulate the baby's first breath. Chemically, the baby senses a decrease in oxygen and an increase in carbon dioxide levels, triggering the respiratory centers in the brain to start the breathing process. Thermally, exposure to the cooler air outside the womb stimulates the baby's skin receptors, encouraging the baby to take a breath. Mechanically, the pressure changes during delivery and the physical stimulation of the baby's face and body also play a role in initiating respiration. Overall, it is the combined effect of these chemical, thermal, and mechanical factors that help a newly delivered baby begin breathing independently.
Multiparous patient admitted to labor unit with regular contractions 2 minutes apart and last 60 seconds. She reports labor began 6 hours ago and she had bloody show earlier this morning.The patient asks what stage of labor she is in
- A. Transition phase
- B. Active phase
- C. Latent phase
- D. Second stage
Correct Answer: B
Rationale: Based on the information provided, the patient is experiencing regular contractions 2 minutes apart lasting 60 seconds, and she had a bloody show earlier in the morning. These signs in a multiparous patient with 6 hours of labor indicate she is most likely in the transition phase of labor. The transition phase is characterized by intense contractions that are closer together, typically 2-3 minutes apart, and lasting longer, usually around 60-90 seconds. This stage signifies the progression towards the final stages of labor, leading up to the pushing stage and delivery. Therefore, the correct answer is B, Transition phase.