Nokea
The doctor has ordered a contraction stress test. The nurse should interpret which of the following as a negative test?
- A. The fetal heart remains stable in relation to 3 contractions.
- B. The uterine contractions last longer than 90 seconds.
- C. The mother reports a pain level that is less than 5 on a 10-point scale.
- D. The baby moves spontaneously 3 times in 20 minutes.
Correct Answer: A
Rationale: A negative contraction stress test indicates that the fetal heart rate remains stable during contractions, suggesting no fetal distress.
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What point in the pregnancy is the most accurate time to determine gestational age through ultrasound?
- A. First trimester
- B. Second trimester
- C. Third trimester
- D. No difference in accuracy among the trimesters
Correct Answer: A
Rationale: The correct answer is A: First trimester. During the first trimester, gestational age can be accurately determined through ultrasound by measuring the crown-rump length of the fetus. This measurement is most accurate during this time as the fetus is small and growth is consistent. In the second and third trimesters, other factors such as fetal growth variations and positioning can affect the accuracy of gestational age determination. Therefore, the first trimester is the most accurate time for determining gestational age through ultrasound. Other choices are incorrect because the precision of ultrasound measurements decreases as pregnancy progresses, making the first trimester the optimal window for accurate gestational age assessment.
A nurse is completing a minimum data set. Which area is the nurse working?
- A. Nursing center
- B. Psychiatric facility
- C. Rehabilitation center
- D. Adult day care center
Correct Answer: A
Rationale: Nurses who work in a nursing center (nursing home or nursing facility) are required to complete a minimum data set on each patient. Minimum data set is not needed for psychiatric, rehabilitation, or adult day care centers.
The nurse who has just performed a vaginal examination notes that the fetus is in the LOP position. Which of the following clinical assessments would the nurse expect to note at this time?
- A. Complaints of severe back pain.
- B. Rapid descent and effacement.
- C. Irregular and hypotonic contractions.
- D. Rectal pressure with bloody show.
Correct Answer: A
Rationale: The LOP (left occiput posterior) position often causes back pain due to the fetal head pressing against the mother’s sacrum.
A baby is exhibiting signs of neonatal abstinence syndrome. Which action would be appropriate for the nursery nurse to make?
- A. Cover the baby with at least two blankets.
- B. Stimulate the baby with rattles.
- C. Play soft classical music in the nursery.
- D. Attach a mobile to the crib.
Correct Answer: A
Rationale: Neonatal abstinence syndrome babies are sensitive to stimuli, so minimizing environmental stimulation, such as by swaddling, is important.
A client presents to Labor & Delivery for an ultrasound at 16 weeks gestation for vaginal bleeding. She asks the nurse if the procedure will harm her baby. Which is appropriate for the nurse to tell the client?
- A. Since you are already bleeding, we cannot guarantee that the ultrasound will not have any negative effects on your pregnancy.'
- B. Ultrasounds use sound waves to view your baby, not radiation, so the procedure will not harm your baby.'
- C. There are no guarantees when you have a procedure performed.'
- D. The doctor wouldn't try to order a test that would hurt your baby.'
Correct Answer: B
Rationale: The correct answer is B: "Ultrasounds use sound waves to view your baby, not radiation, so the procedure will not harm your baby."
Rationale:
1. Ultrasound uses sound waves, not radiation, to create images of the baby in the womb.
2. The sound waves are considered safe for both the mother and the developing baby.
3. There is no evidence to suggest that ultrasound procedures pose any harm to the pregnancy.
4. It is important to reassure the client that the ultrasound is a routine procedure and will not harm the baby.
Summary:
Choice A is incorrect because it wrongly implies that the ultrasound could potentially harm the baby due to the existing bleeding, which is not true.
Choice C is incorrect as it does not provide specific information regarding the safety of ultrasound during pregnancy.
Choice D is incorrect as it lacks the specific information about the safety of ultrasound and relies on a general statement about the doctor's intentions.