Nokea
The nurse is performing a prenatal assessment. What finding is considered a positive sign of pregnancy?
- A. Positive pregnancy test.
- B. Auscultation of fetal heart tones.
- C. Hegar's sign.
- D. Chadwick's sign.
Correct Answer: B
Rationale: The correct answer is B, auscultation of fetal heart tones, because it is a definitive sign of pregnancy indicating the presence of a fetus. This can be heard around 10-12 weeks of gestation using a Doppler device. It is a positive sign as it directly confirms the existence of a developing fetus.
A: A positive pregnancy test is a probable sign and can indicate pregnancy but is not definitive.
C: Hegar's sign is a probable sign characterized by softening of the lower uterine segment, not specific to pregnancy.
D: Chadwick's sign is a probable sign of pregnancy indicated by bluish discoloration of the cervix, vagina, and labia, not a definitive sign of pregnancy.
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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.
Which finding in a laboring mother requires immediate intervention?
- A. Contractions occurring every 5 minutes
- B. Late decelerations on fetal heart monitor
- C. Early decelerations on fetal heart monitor
- D. Elevated maternal temperature during labor
Correct Answer: D
Rationale: The correct answer is D: Elevated maternal temperature during labor. This finding indicates a potential infection, such as chorioamnionitis, which can be harmful to both the mother and the baby if not promptly treated. Immediate intervention is necessary to prevent complications like sepsis.
Contractions every 5 minutes (A) are within the normal range for active labor. Late decelerations (B) can indicate uteroplacental insufficiency and require monitoring but not immediate intervention unless persistent. Early decelerations (C) are usually benign and do not typically require immediate action.
The nurse is aware that a pre-term neonate may have a potential nutritional problem because of:
- A. Poor sucking reflex
- B. A decreased metabolic rate
- C. Decreased caloric requirement
- D. Increased absorption of nutrients
Correct Answer: A
Rationale: The correct answer is A: Poor sucking reflex. Pre-term neonates often have immature sucking reflexes, which can lead to difficulty in feeding and obtaining adequate nutrition. This can result in a potential nutritional problem. Option B is incorrect because pre-term neonates actually have an increased metabolic rate to support their growth and development. Option C is incorrect as pre-term neonates have increased caloric requirements due to their rapid growth. Option D is incorrect as pre-term neonates typically have decreased absorption of nutrients due to an immature gastrointestinal system.
A nurse is assessing a client who is 3 days postpartum and is breastfeeding. The nurse notes that the fundus is three fingerbreadths below the umbilicus, lochia rubra is moderate, and the breasts are hard and warm to palpation. Which of the following interpretations of these findings should the nurse make?
- A. The client is exhibiting early indications of mastitis.
- B. Additional interventions are not indicated at this time.
- C. Application of a heating pad to the breasts is indicated.
- D. The client should be advised to remove her nursing bra.
Correct Answer: B
Rationale: Correct Answer: B - Additional interventions are not indicated at this time.
Rationale:
1. Fundus location: Three fingerbreadths below the umbilicus is within normal range for 3 days postpartum.
2. Lochia rubra: Moderate lochia rubra is expected at this stage postpartum.
3. Breasts: Hard and warm breasts are indicative of engorgement, a common issue in breastfeeding mothers.
Summary:
A: Early indications of mastitis would include redness, warmth, and tenderness in the breasts, along with flu-like symptoms.
C: Application of a heating pad to the breasts can worsen engorgement and increase the risk of mastitis.
D: Removing a nursing bra may offer some relief for engorgement, but it is not the priority intervention at this time.
A client is admitted with a vaginal bleeding at 10 weeks' gestation and her fundal height 13cm. Which potential problem should you investigate?
- A. Hydatidiform mole
- B. DIC
- C. Previa
- D. Abruptio placenta
Correct Answer: C
Rationale: The correct answer is C: Previa. At 10 weeks' gestation, fundal height should be close to the pelvic brim, not 13cm above it. This suggests placenta previa, where the placenta implants low in the uterus, causing bleeding. Hydatidiform mole would typically present with earlier bleeding and a larger uterus. DIC and abruptio placenta are not supported by the information given at this gestational age.