Nokea
A client in the third trimester reports severe itching without rash. What condition should the nurse suspect?
- A. Cholestasis of pregnancy.
- B. Preeclampsia.
- C. Gestational diabetes.
- D. Fungal infection.
Correct Answer: A
Rationale: Severe itching in pregnancy without a rash is commonly associated with cholestasis of pregnancy.
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A nurse is caring for a client who is in the first stage of labor, undergoing external fetal monitoring, and receiving IV fluid. The nurse observes variable decelerations in the fetal heart rate on the monitor strip. Which of the following is a correct interpretation of this finding?
- A. Variable decelerations are due to umbilical cord compression.
- B. Variable decelerations are caused by uteroplacental insufficiency.
- C. Variable decelerations are a result of the administration of IV narcotic analgesics.
- D. Variable decelerations are related to fetal head compression.
Correct Answer: A
Rationale: Variable decelerations in the fetal heart rate are due to umbilical cord compression. These decelerations are characterized by an abrupt decrease in the fetal heart rate that is variable in duration, depth, and timing in relation to the uterine contraction. They can signify compression of the umbilical cord leading to transient interruption of fetal oxygen supply. It is essential for the nurse to promptly identify variable decelerations and take appropriate actions to alleviate the compression, such as repositioning the client to relieve pressure on the cord.
What is the purpose of a Pap smear during preconception screening?
- A. to check for anemia or other blood disorders
- B. to evaluate thyroid hormone levels
- C. to screen for cervical cancer or detect abnormal cervical cells
- D. to assess cholesterol levels and cardiovascular health
Correct Answer: C
Rationale:
A nurse is admitting a client who has a diagnosis of preterm labor. The nurse anticipates a prescription by the provider for which of the following medications? (Select all that apply.)
- A. Prostaglandin E2
- B. Indomethacin
- C. Magnesium sulfate
- D. Methylergonovine
Correct Answer: A
Rationale: A. Prostaglandin E2: Prostaglandin E2 is used to manage preterm labor by helping to ripen the cervix and promote contractions.
The nurse is conducting a prenatal class on the female reproductive system. When a client asks why the fertilized ovum stays in the fallopian tube for 3 days, what is the best response?
- A. It promotes the fertilized ovum's chances of survival.
- B. It promotes the fertilized ovum's exposure to estrogen and progesterone.
- C. It promotes the fertilized ovum's normal implantation in the top portion of the uterus.
- D. It promotes the fertilized ovum's exposure to luteinizing hormone and follicle-stimulating hormone.
Correct Answer: C
Rationale: The delay ensures the ovum reaches the uterus at the right developmental stage for proper implantation in the upper uterine segment.
The nurse is monitoring a client at 39 weeks' gestation receiving oxytocin for labor induction. What finding requires the nurse to stop the infusion?
- A. Contractions every 2–3 minutes.
- B. Contractions lasting 120 seconds.
- C. Baseline fetal heart rate of 140 beats/minute.
- D. Client reports mild back pain.
Correct Answer: B
Rationale: Contractions lasting longer than 90 seconds indicate uterine hyperstimulation and can compromise fetal oxygenation.