Nokea
A client at 34 weeks' gestation is diagnosed with polyhydramnios. What is the nurse's priority assessment?
- A. Monitor maternal blood pressure.
- B. Assess for signs of preterm labor.
- C. Check for signs of infection.
- D. Evaluate for fetal heart rate changes.
Correct Answer: B
Rationale: Polyhydramnios increases the risk of preterm labor due to uterine overdistension, requiring close monitoring.
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What emergency contraception has the best efficacy for prevention of pregnancy?
- A. Plan B
- B. Yuzpe
- C. copper IUC
- D. progesterone-only EC
Correct Answer: C
Rationale: Copper intrauterine devices (IUDs) have the best efficacy for prevention of pregnancy among emergency contraception options. Copper IUDs are over 99% effective when used as emergency contraception, making them more reliable than other methods like Plan B, Yuzpe, or progesterone-only EC. This high efficacy is due to the mechanism of action of copper IUDs, which prevent fertilization and implantation of the fertilized egg. Additionally, once inserted, a copper IUD can continue to provide ongoing contraception for up to 10 years, making it a long-term contraceptive option as well.
The newborn's mother is concerned about the shape of the baby's head after delivery. She states that the baby looks like a "cone head." What is the most appropriate response by the nurse?
- A. "You don't need to worry about it. It is perfectly normal after birth."
- B. "It is molding caused by the pressure during birth and will disappear in a few days."
- C. "I will report it to the physician and recommend a diagnostic scan."
- D. "It is a collection of blood related to the trauma of delivery and will absorb in a few weeks.
Correct Answer: B
Rationale: "It is molding caused by the pressure during birth and will disappear in a few days."
The nurse is caring for a postpartum client who is
- A. Maternal hyperglycemia 1 day postcesarean birth. What assessment data
- B. FHR, early decelerations would indicate infection? Select all that apply.
- C. FHR, late decelerations
- D. Increased pulse
Correct Answer: A
Rationale: Maternal hyperglycemia 1 day post-cesarean birth can indicate infection. Hyperglycemia can impair immune function and make the body more susceptible to infections.
What history would lead you to suspect an ectopic pregnancy in a client at 8 weeks' gestation presenting with abdominal pain and bleeding?
- A. Treated one year ago for PID
- B. Irregular cycle for 1 year
- C. Oral contraception for 3 years
- D. Urinary frequency for 1 week
Correct Answer: A
Rationale: A history of previous pelvic inflammatory disease (PID) treatment would lead to suspicion of an ectopic pregnancy in a client presenting with abdominal pain and bleeding at 8 weeks' gestation. PID can cause scarring and damage to the fallopian tubes, increasing the risk of an ectopic pregnancy where the fertilized egg implants outside of the uterus, usually in the fallopian tubes. Symptoms of an ectopic pregnancy can include abdominal pain, vaginal bleeding, and signs of shock, making it important to consider this possibility in a client with a history of PID.
The nurse is educating a male patient on how a vasectomy works. What is the best explanation for this procedure?
- A. The procedure blocks the sperm from entering into the semen and being ejaculated.
- B. The procedure removes the testicle so that sperm are not made.
- C. The tube that carries seminal fluid is blocked, causing no semen to be ejaculated.
- D. The procedure kills all sperm so they are unable to make it to the ovulated egg.
Correct Answer: A
Rationale: A vasectomy involves blocking or cutting the vas deferens to prevent sperm from being ejaculated with semen, making it an effective method of contraception. Choice B is incorrect because the testicles are not removed during a vasectomy, only the vas deferens is altered. Choice C is incorrect because seminal fluid is still produced, but sperm are prevented from entering it. Choice D is incorrect because sperm are not killed, but rather prevented from mixing with semen.