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The nurse is discussing danger signs during preg- tion procedure. Which statement is appropriate for nancy with a pregnant woman in her first trimester. the nurse to make? Which of the following signs and symptoms would
- A. A catheter is inserted through the cervix into the be appropriate at this time? Select all that apply.
- B. Severe headache and visual changes
- C. Persistent vomiting and nausea
- D. Sperm or ovarian tissue will be frozen for
Correct Answer: B
Rationale: The correct answer is B. Severe headache and visual changes are potential danger signs during the first trimester of pregnancy, indicating conditions like preeclampsia. This is crucial to monitor as it can lead to serious complications for both the mother and the baby.
Choice A is incorrect because inserting a catheter through the cervix is not a relevant danger sign during the first trimester. Choice C, persistent vomiting and nausea, is commonly experienced in the first trimester as morning sickness and is not typically a sign of immediate danger. Choice D, freezing sperm or ovarian tissue, is unrelated to discussing danger signs during pregnancy and does not indicate any potential issues during the first trimester.
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A nurse is teaching a client who is at 41 weeks of gestation about a non-stress test. Which of the following information should the nurse include in the teaching?
- A. "This test will confirm fetal lung maturity ".
- B. "This test will determine adequacy of placental perfusion".
- C. "This test will detect fetal infection".
- D. "This test will predict maternal readiness for labor".
Correct Answer: B
Rationale: The correct answer is B: "This test will determine adequacy of placental perfusion." The non-stress test is used to assess fetal well-being by monitoring fetal heart rate in response to fetal movement. It helps determine if the placenta is providing enough oxygen and nutrients to the fetus. This information is crucial in assessing the overall health and viability of the fetus.
A: "This test will confirm fetal lung maturity" - This statement is incorrect because the non-stress test does not assess fetal lung maturity. That is usually done through tests like amniocentesis.
C: "This test will detect fetal infection" - This statement is incorrect because the non-stress test does not detect fetal infection. Other tests like amniocentesis or blood tests are used for this purpose.
D: "This test will predict maternal readiness for labor" - This statement is incorrect as the non-stress test focuses on fetal well-being and does not predict maternal readiness for labor.
The nurse is assessing a client in the third trimester with suspected gestational diabetes. What symptom is most concerning?
- A. Increased thirst and urination.
- B. Fasting blood glucose of 100 mg/dL.
- C. Weight gain of 1 pound in a week.
- D. Proteinuria of +1.
Correct Answer: A
Rationale: The correct answer is A: Increased thirst and urination. In gestational diabetes, increased thirst and urination can indicate uncontrolled blood sugar levels, which can harm the fetus. This symptom suggests hyperglycemia and requires immediate intervention.
B: Fasting blood glucose of 100 mg/dL is within the normal range for pregnancy and not concerning.
C: Weight gain of 1 pound in a week can be normal in the third trimester and not specific to gestational diabetes.
D: Proteinuria of +1 is more concerning for preeclampsia rather than gestational diabetes.
After several hours of labor, the fetal heart monitor shows
- A. The nurse would interpret this deceleration to be consistent with which presentation?
- B. Umbilical cord compression
- C. Uteroplacental insufficiency
- D. Compression of fetal head
Correct Answer: B
Rationale: The correct answer is B: Umbilical cord compression. When the fetal heart monitor shows deceleration after several hours of labor, it indicates reduced oxygen supply to the fetus. Umbilical cord compression can restrict blood flow and oxygen delivery to the fetus, leading to decelerations. This is a common cause during labor. Choices A, C, and D do not directly relate to the decreased oxygen supply indicated by decelerations on the fetal heart monitor.
A newborn is suspected of having substance abuse instructions? exposure. Which of the following assessment findings
- A. Exercise will decrease my metabolism and should the nurse expect? Select all that apply.
- B. Increased weight gain
- C. Starting on Glucophage will take the place of
- D. Seizures
Correct Answer: D
Rationale: The correct answer is D: Seizures. Substance abuse exposure in a newborn can lead to withdrawal symptoms, including seizures. This is because the newborn's central nervous system may have been affected by the substances. Seizures are a serious medical emergency and require immediate attention.
Explanation for why other choices are incorrect:
A: Exercise and metabolism are not directly related to substance abuse exposure in a newborn.
B: Increased weight gain is not a typical assessment finding for newborns with substance abuse exposure.
C: Glucophage is a medication used to treat diabetes, and it does not relate to substance abuse exposure in a newborn.
How can a nurse best prevent heat loss in a newborn during the first hour of life?
- A. Place the newborn under a radiant warmer
- B. Dry the newborn and cover with a warm blanket
- C. Place the newborn in a skin-to-skin position with the mother
- D. Keep the newborn wrapped in a wet blanket
Correct Answer: A
Rationale: The correct answer is A: Place the newborn under a radiant warmer. This method is the most effective in preventing heat loss in a newborn as radiant warmers provide a consistent heat source to maintain the newborn's body temperature. This is crucial during the first hour of life when newborns are at a higher risk of hypothermia.
Choice B is not as effective as using a radiant warmer as it may not provide enough warmth to prevent heat loss. Choice C, placing the newborn in a skin-to-skin position with the mother, is beneficial for bonding and regulating the newborn's temperature in the long term but may not be as effective as a radiant warmer in the immediate post-birth period.
Choice D, keeping the newborn wrapped in a wet blanket, is incorrect as wet blankets can further contribute to heat loss through evaporative cooling. In summary, using a radiant warmer is the best option for preventing heat loss in a newborn during the critical first hour of life.