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A client in labor with a breech presentation is scheduled for a cesarean delivery. What is the nurse's priority action?
- A. Obtain baseline maternal vital signs.
- B. Assist with positioning for spinal anesthesia.
- C. Verify fetal heart tones before the procedure.
- D. Ensure signed informed consent is on file.
Correct Answer: D
Rationale: Ensuring signed informed consent is a priority before any surgical procedure, including cesarean delivery.
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The nurse is providing instructions to a pregnant client who is scheduled for an amniocentesis. What instruction should the nurse provide?
- A. Strict bed rest is required after the procedure.
- B. Hospitalization is necessary for 24 hours after the procedure.
- C. An informed consent needs to be signed before the procedure.
- D. A fever is expected after the procedure because of the trauma to the abdomen.
Correct Answer: C
Rationale: Informed consent is essential before an invasive procedure like amniocentesis. Monitoring post-procedure symptoms is also crucial.
A nurse is caring for a client who is in active labor with 7 cm of cervical dilation and 100% effacement. The fetus is at 1+ station, and the client's amniotic membranes are intact. The client suddenly states that she needs to push. Which of the following actions should the nurse
- A. Assist the client into a comfortable position.
- B. Observe the perineum for signs of crowning.
- C. Have the client pant during the next contractions.
- D. Help the client to the bathroom to void.
Correct Answer: B
Rationale: The sudden urge to push along with the advanced cervical dilation, effacement, and station indicates that the client is likely in the second stage of labor, which is the stage of active pushing. When a woman feels the urge to push, it is essential to assess for the crowning of the fetal head at the perineum as this indicates that the baby is descending and will soon be born. This assessment helps the nurse determine the appropriate actions to take next in assisting the delivery process. Waiting for signs of crowning before guiding the client to push can prevent potential complications related to a rapid birth and help facilitate a more controlled delivery process.
A nurse is doing genetic counseling with a couple. give to a client undergoing a mastectomy? The mother has Down syndrome and the father
- A. Tylenol should be avoided after surgery. has no chromosomal abnormalities. What is the
- B. The affected arm should remain in a sling for chance of their offspring being affected by this 4 weeks. disorder?
- C. The client should expect the affected arm to be
- D. 25%
Correct Answer: D
Rationale: When a woman with Down syndrome (trisomy 21) has a child with a man who does not have any chromosomal abnormalities, the chance of their offspring having Down syndrome is 25%. This is because the mother can only pass on one copy of the extra chromosome 21 to her child, resulting in a 50% chance of passing it on. However, since the father does not have an extra chromosome 21 to contribute, the overall chance of the child having Down syndrome is reduced to 25%.
What is a common risk factor for breast cancer? Select all that apply.
- A. being assigned female at birth
- B. having a first-degree relative with breast cancer
- C. carrying mutations in BRCA1 and BRCA2 genes
- D. being of African American ethnicity
Correct Answer: A,B,C
Rationale:
The nurse assigned to the care of newborn infants understands the importance of keeping these infants swaddled in a warm blanket to prevent heat loss. Why is this important in the care of the newborn?
- A. Chilling leads to increased heat production and greater oxygen needs.
- B. The newborn's metabolic rate is decreased.
- C. Evaporation will affect the newborn's ability to feed.
- D. The newborn will sleep more comfortably.
Correct Answer: A
Rationale: Swaddling newborn infants in a warm blanket is important to prevent heat loss (hypothermia) because when babies become chilled, they must produce more heat to maintain a normal body temperature. This increased heat production leads to higher oxygen needs, which can be detrimental to newborns who may already have limited reserves. Therefore, keeping newborn infants swaddled in a warm blanket helps to maintain their body temperature within a normal range and prevents unnecessary stress on their bodies.